THE INFLUENCE OF SEXUALITY EDUCATION AND SUPERVISION,

CLINICAL EXPERIENCE, PERCEIVED SEX KNOWLEDGE, AND

COMFORT WITH SEXUAL CONTENT ON THERAPISTS

ADDRESSING SEXUALITY ISSUES WITH CLIENTS

by

KELLl WENNER HAYS, B.A., M.S.Ed.

A DISSERTATION

IN

MARRIAGE AND FAMILY THERAPY

Submitted to the Graduate Faculty of Texas Tech University in Partial Fulfillment of the Requirements for the Degree of DOCTOR OF PHILOSOPHY

Approved T3

,TO,^^ ACKNOWLEDGMENTS

I would like to express my gratitude and appreciation for Dr. Steven Harris, my committee chair and advisor. His guidance throughout this project and my graduate degree has made me a better researcher and clinician. I would also like to thank my committee members for all of the time that they devoted to helping me successfully complete this project. Specifically, I would like to thank Dr. Dean Busby for his patience with me while he shared his statistical expertise with a novice; Dr. Kary Reid for creating a path to a clinical practice that incorporates and celebrates human sexuality and encouraging others to do the same; Dr. Sheila Garros for the abundance of valuable feedback on my manuscripts and for your passion and expertise for sexuality research. I could not have chosen a more helpfiil and diligent committee. Additionally, I would like to thank my parents for their unending encouragement, love and support. I would not be in higher education if they had not believed in me and instilled a belief in myself The sacrifices that they made on my behalf and for my education have not gone unnoticed or unappreciated. My parents and family have continually supported me throughout my academic endeavors. Nichole Morelock, thank you for being my study partner, stress reducer, and voice of validation during our doctoral program. Most of all 1 would like to thank Nichole, Trina Powers and Amelia Matlack for their friendship and words of encouragement throughout this experience. Lastly. I would like to thank my husband. Buddy. He has been my voice of reason and source of motivation during this project. His never- ending positive attitude has calmed my fears and helped me to find alternative solutions to problems. He has always encouraged me to dream big and has believed that I was capable of reaching those dreams. Thank you for helping this dream to come true.

11 TABLE OF CONTENTS

ACKNOWLEDGEMENTS

ABSTRACT ii

LIST OF TABLES vi

LIST OF FIGURES vii

CHAPTER viii

I. THE PROBLEM

Introduction 1

Importance of the Study 1

Statement of the Problem 5

General Hypotheses 6

Definition of Terms 7

Summary 8

II. REVIEW OF LITERATURE 9

Introduction 10

Family Systems Theory 10

Therapist Knowledge About Sex 12

Therapist Sexuality Education 20

Marriage and Family Therapists' Sexuality 24

Education 28

Therapist Comfort with Sexual Matters 31

Summary 34

iii III. PROCEDURES 35 Introduction 35 Restatement of the Problem 35 Description of Sampling Procedure 35 Procedures 36 Instrumentation 39 Sexuality Education scale 41 Clinical Experience scale 41 Experience in Supervision scale 41 Sex Knowledge and Attitude Test (SKAT) 41 Sexual Comfort scale 44 Sexuality Discussions scale 45 Research Questions and Hypotheses 45 Research Design and Analyses 52 Summary 55 IV. RESULTS 56 Introduction 56 Demographic Characteristics of the Sample 56 Preliminary Analyses 61 Tests of Hypotheses 66 Summary 73

iv V. DISCUSSION 75 Introduction 75 Summary of the Study 75 Interpretation of Study Results 78 Methodological Strengths and Limitations 84 Directions for Future Research 88 Clinical Implications for Marriage and Family Therapists 91 REFERENCES 95 APPENDICES 100 A. THE TEXAS TECH UNIVERSITY COMMITTEE FOR THE PROTECTION OF HUMAN SUBJECTS APPROVAL LETTER 100 B. PRENOTICE LETTER 102 C. COVER LETTER 104 D. QUESTIONNAIRE 106 E. REMINDER POSTCARD 114 F. FOLLOW-UP LETTER AND REPLACEMENT QUESTIONNAIRE 116 G. OMITTED QUESTIONS THAT WERE IDENTIFIED AS QUESTIONABLE BY THE AUTHOR OF THE SKAT 118 H. ADDITIONAL OMITTED QUESTIONS THAT WERE CONSIDERED IRRELEVANT OR OUTDATED 120 ABSTRACT

The purpose of this investigation was to examine if marriage and family therapists are initiating sexuality related discussions with their clients. Five variables were hypothesized to either directly or indirectly influence the dependent variable: therapist sexuality education, therapist clinical experience with sexuality issues, experience addressing sexuality issues in supervision, therapist sex knowledge and therapist level of comfort with sexuality issues. The theoretical literature has focused on sexuality education, clinical experience and supervision experience as important in moderating therapists' sex knowledge and comfort with sexuality issues. Previous research also indicates therapists' sex knowledge as an influential factor on therapists' comfort with sexual issues. However, virtually no empirical research has been previously conducted to test these variables. Additionally, there has been no previous empirical research that directly addresses the influencing factors of therapists' willingness to address sexuality issues with clients.

A national random sample of 175 clinical members of the American Association for Marriage and Family Therapists (AAMFT) completed a 48-item questionnaire.

Participants answered questions that assessed their past, current, and perceived experience and knowledge with sexuality issues. The findings suggest that therapists' perceived sex knowledge is a better predictor of their likelihood to engage in sexuality discussions than their actual sex knowledge. Therapists' comfort with sexual content and sexuality education, both had significant effects on the dependent variable. Implications for these findings are discussed and suggestions for future research are provided.

vi LIST OF TABLES

1. Initial Scale Names, Example Questions, and Reliability Scores

2. Measures of Central Tendency and Variance for Demographic Variables 40

3. Demographic Characteristics 58

4. Pearson Correlations for Original Path Model Variables 59

5. Means, Standard Deviations, and Ranges of Variables in the Final Path 63 Model

6. Pearson Correlations for Exogenous and Endogenous Variables 67

7. Decomposition Table 67

72

Vll LIST OF FIGURES

1. Initial Path Model

2. Adjusted Inifial Path Model 53

3. Final Path Model 65

68

Vlll CHAPTER I

THE PROBLEM

"Sex lies at the root of life, and we can never learn to reverence life until we know how to understand sex." (Havelock Ellis, 1952)

Introduction

Relevance of Sexuality Discussions in Therapy

Therapist-client discussions that address sexuality matters should affirm sexuality and promote sexual health while striving to prevent unsafe sexual sharing (Stayton,

1998). Approached from this perspective, sexuality is understood as an extensive topic that serves as a fundamental component to an overall positive self-esteem (National guidelines task force, 1996). Clients at all ages are dealing with sexuality issues in their life, some more successfully than others. To name a few of the sexually related issues faced during the life cycle: children are learning the names of their body parts as well as developing feelings towards their bodies and specific body parts; adolescents are struggling with sexual expression, values and fears related to developing a sexual identity; couples in committed relationships often encounter matters of sexual satisfaction, frequency, pregnancy, and varied forms of expression; and older adults are facing changes in body, body image and sexual performance. As therapists encourage people to embrace their sexuality, beyond the realms of the act of sexual intercourse, clients are able to conceptualize their sexuality as a positive aspect of their identity.

In a study on couples' perceptions of effective and ineffective ingredients of marital therapy, Estrada and Holmes (1999) found that the couples' statements focused

1 largely on the therapists' behavior. Mainly, subjects expected therapists to be active, structured, and focused in therapy while at the same time creating a safe environment.

Creating a safe environment for therapy involves creating a non-threatening environment that enables clients to address difficult issues. Thus when therapists initiate conversations about socially labeled taboo topics such as sexuality, their clients may be more willing to initiate discussions involving sexuality in future sessions. In other words, the therapist's ability to initiate sexuality-related discussions with clients serves as a model for future conversations with their clients. Additionally, therapists discussing

sexuality issues with clients may provide a model for initiating sexuality-related

discussions outside of therapy. For instance, parents will occasionally ask therapists to

talk with their children about sexual issues. Likewise, parents will ask therapists for

specific ways in which they can discuss sexual issues with their children. In these and

similar situations, therapists are sometimes apprehensive to initiate explicit discussions of

such issues, which often stems from a lack of knowledge and comfort in the area (White

&DeBlassie, 1992).

Parents are the earliest and most important influence on sexuality. Parents

provide children with their first understanding of gender roles, relationships, body image,

values, and their sense of self-esteem. A study by White and DeBlassie (1992) rated

parents highest in terms of influence on sexual opinions, beliefs, and attitudes, but lower

than friends, school, and books as sources of sexual information. Parents may avoid this

area of discussion because many have great difficulty accepting their children as sexual

individuals. Additionally, parents are often handicapped by limited knowledge as well as

societal strictures against the discussion of explicit sexual matters within the family.

2 Despite these hindrances, more than 8 out of 10 parents report that they want help in providing sexuality education for their children (Haffner & Mauro, 1991).

Couples, parents and children are not the only ones facing sexuality issues that

warrant discussion. One of the most neglected areas of research and clinical practice has

been sexuality and the aging process (Harris, Dersch, Kimball, Marshall, & Negretti,

1999; Stayton, 1998). Many individuals in the general population as well as in the health

care community still harbor archaic myths and misconceptions regarding sexuality and

older individuals (Calamidas, 1997). This is of great concern, since any interaction with

an aging population has the "potential for confirming or disavowing the legitimacy of

sexuality for the elderly, thereby affecting the quality of care" (Glass & Webb, 1995,

p. 176). Of even greater concern, is that health care professionals are particularly ill

prepared in matters concerning sexuality and aging (Harris et al., 1999; Karlen & Moglia,

1995).

Saying Nothing is Saving Something

American culture is saturated with hyper-sexual messages fi"om the media, yet

individual expressions of sexuality are often repressed (Stayton, 1998). While both

parents and professionals agree that parents bear the primary responsibility for their

children's sexuality education, research to date indicates that: (1) most parents have

abdicated their responsibility, and (2) peers and the media have become the primary

sources of information regarding sexuality (Moore & Davidson, 1999). Regardless of

how positive a behavioral role model parents may provide, silence teaches children that sexuality is not a subject that can be discussed, and in fact few people have open, in- depth discussions about their sexuality (Stayton, 1998).

A strong negative message may be conveyed if parents are silent about sex.

Because of the lack of communication about sex in many families, young people have

been trained not to talk about these "private" issues with their parents or other adults.

Such silence may connote a negative value to the subject, suggesting there is something

secretive, mysterious or even bad about sexuality, thus contributing to guilt and confusion

associated with the issue.

Moreover, "silent lessons of sex" are never neutral: if not positive, they

contribute to negative consequences in self-concept and interpersonal relationships

(Moore, 1985). Silence on the part of parents regarding sexual issues can be interpreted

as placing value on being secretive. The negative impact of this can also direct therapy,

since, "... even to do and say nothing in response to the patient's questions and/or

presentation of symptoms in the sexual and marital area is, by default, one form of

counseling" (Driscoll, Coble, & Caplan, 1982, p.201). A value of secrecy, like many

other values, is often carried-over into adulthood and can become part of one's self-

identity.

Human sexuality is a sensitive subject to most people and accurate information is

not always accessible. Engel, Saracino, and Bergen (1993) have suggested that what is

learned about sexuality is mediated by the process of how it is learned, including the timing and how the information is presented. Most people are not accustomed to reading about or discussing such private matters. Therefore, it cannot be assumed that clients will initiate a discussion about sexual issues even when it is an area of concern for them. In

4 the same manner, it cannot be assumed that clients will report sexual concerns that need to be addressed in therapy during an initial session or during assessment. If the therapist fails to initiate discussion or inquire about sexual concerns, clients may interpret their silence into a familiar message that sexual discussions are taboo.

Importance of the Studv

While mental health professional literature has repeatedly addressed the relevance of therapist sex knowledge and comfort with sexual matters, few studies (Arnold, 1980;

Fluharty, 1995) have done more than assess the efficacy of various training models of human sexuality. Likewise previous research has shown it is important for therapists to address sexual issues with clients (Bonner & Gendel, 1989; Christensen, Norton, Salisch,

& Gull, 1977; Gray, Cummins, Johnson, & Mason, 1989; Kell, 1992; Landis, Miller, &

Wettstone, 1975) few studies have explored the variables that might influence these discussion with clients. Futhermore, no previous research has looked at this phenomenon as it pertains specifically to marriage and family therapists. The lack of empirical data on factors that measure and contribute to marriage and family therapists discussing sexuality-related matters with clients is remarkable given the volume of literature that exists on treatment-specific sexual topics (see Wincze & Carey, 2001), sexuality training

(Drolet & Clark 1994; Fyfe, 1980; Stayton, 1998; Weerakoon, & Stiemborg, 1996) and the likelihood that therapists will be faced with their clients' issues related to sexuality

(Gray et al., 1989; Landis et al., 1975; Stayton, 1998).

Since this aspect of therapy is not well understood, it is critical that research be conducted to answer the following basic questions regarding therapists' discussions of

5 sexuality-related issues with clients: (1) How can therapists' discussion of sexuality- related matters with clients be measured? (2) Does either sexuality education, clinical experience with sexuality issues, or a positive supervision experience which addresses sexuality issues influence (a) the sex knowledge of therapists, or (b) therapists' comfort

level with sexuality issues?, (3) Does therapists' sexual knowledge mitigate his or her comfort with sexuality issues? and, (4) Does therapists' sex knowledge and level of

comfort with sexual matters influence his or her discussions of sexuality-related topics with clients? The answers to these questions are addressed in this investigation using

Bowen family systems theory as a theoretical base from which to understand therapist

anxiety and identify variables that influence therapists likelihood to initiate sexuality-

related discussions with their clients.

Statement of the Problem

To date, minimal empirical data have been published concerning how therapists

can effectively initiate sexuality-related discussions with clients, despite the fact that

numerous surveys have suggested mental health professionals are not sufficiently trained

to work with such issues. The aim of the present study was to determine to what extent

formalized sexuality education, clinical experience with sexual issues, and positive

supervision experience that addresses sexual issues, basic sexual knowledge, and therapist comfort with sexual topics influences whether or not MFTs are having discussions with clients about sexuality issues. The influence of therapist sexual knowledge on therapist comfort with sexual matters was also explored. Additionally, the influences of therapist formal sexual education, clinical experience with sexual issues and

6 positive supervision experience addressing sexual issues on both, basic sexual knowledge and level of comfort with sexuality-related topics was studied. These variables were selected because of the frequency with which they have been hypothesized in the

sexuality literature as influencing the dependent variable (Anderson, 1986; Bonner &

Gendel, 1989; Driscoll et al., 1982; Fyfe, 1980; Graham & Smith, 1984; Gray et al.,

1989; Landis et at., 1975; Stayton, 1998; Yallop & Fitzgerald, 1997). Further review of the literature for each of the dependent and independent variables examined in this study

can be found in Chapter II.

General Hypotheses

The general hypotheses tested in this study are listed below. Overall, they reflect

an effort to examine if marriage and family therapists are having discussions on sexually related topics with their clients. The general hypotheses were:

1(a). Therapists who have graduate school level sexuality education, positive

supervision experiences discussing sexuality matters, and clinical experience

addressing sexuality issues will influence therapists' level of comfort with

sexuality issues; and that (b) therapists' comfort level with sexuality-related

matters will be positively related to therapists' initiated discussions on sexuality-

related topics with clients.

2(a). Therapists with graduate school level sexuality education, positive

supervision experiences discussing sexuality matters, and clinical experience

addressing sexuality issues will influence therapists' knowledge about sexuality-

related matters; and that (b) therapists' sexual knowledge will be related to

7 therapists' comfort level with sexuality-related matters; and that (c) therapists'

sexual knowledge will be positively related to therapists' initiated discussions on

sexuality-related topics with clients.

Definition of Terms

In order to better understand the terminology most frequently used in this study, a number of definitions are provided below.

Graduate level sexuality education: any formal sexuality education received beyond the undergraduate degree.

Non-anxious presence: An increased level of differentiation that enables a person to not respond with emotional reactivity while in an anxious environment, or "containing one's reactivity to the reactivity of others (which includes the ability to avoid being polarized)" (Friedman, 1991).

Positive supervision experience addressing sexuality matters: A formal supervision experience in which sexuality issues were openly addressed by the supervisor when necessary.

Sexuality discussions with clients: (1) The ability of the therapist to create a space for open discussions about sexual issues. (2) Whether therapist or client-initiated, the therapist is able to help clients explore their sexuality and address any concerns or problems. (3) The therapist does not actively avoid sexual discussions with clients.

Sexual knowledge: Any subject matter or material having to do with sex or sexuality that the therapist is aware of (Lief & Reed, 1972). Sexuality-related topics: any subject matter or material having to do with sex or sexuality.

Therapist comfort with sexual matters: The ability of the therapist to: (1) openly discuss sexual feelings and attitudes with clients, (2) respect and accept the client's sexual practices, and (3) communicate effectively about sexuality (Graham & Smith,

1984).

Summary

In Chapter I, the importance of the topic of sexuality-related discussions with clients and variables that may contribute to this construct were discussed. According to professional literature, the negative effects of therapist avoidance of sexual issues has been documented by several sources (Driscoll et al., 1982; Moore, 1985; Stayton, 1998).

Taken from these results is the assumption that therapists should be having open discussions with their clients about sex and sexuality. Though factors that influence the

likelihood of therapists initiating such discussions with clients have been hypothesized, the relevance of these factors had not been tested by previous research. Specifically, differences regarding the engagement in sex and sexuality-related discussions with clients based on therapist sexual knowledge, comfort level, sexuality training, clinical experience and supervision experience have not been explored.

The introduction to the topic was followed by a discussion of the purpose of the present study, the statement of the problem, and the general hypotheses. Chapter I concluded with definitions for frequently used terms. Chapter II provides a comprehensive review of pertinent literature.

9 CHAPTER II

REVIEW OF THE LITERATURE

Introduction

Given the importance of sexuality in our everyday lives, surprisingly little

research documents the overall importance of discussions with clients' about their

sexuality. A common task of clients is solidifying a sense a personal identity. Given that

sexuality is one component of identity, the task of addressing sexual concerns without

also addressing other aspects of life is most likely impossible if not undesirable (National

guidelines task force, 1996). The most common failure of therapists is the avoidance of

sexual issues altogether (Hilton, 1997). Counseling should include all areas of

development, including sexuality (Gilchrist 8c Schinke, 1983). How individuals feel

about their "sexual self will greatly affect their general self-image and confidence.

Thus, one task for the therapist is to help people address sexual concerns that they cannot

resolve independent of therapy.

For example, Schnarch (1997) describes human sexual potential from what he has

termed the "quantum model." This model incorporates two separate dimensions: (1)

physical sensations and responses to sex and (2) thoughts and feelings about sex.

Schnarch separates the two because each has the potential to impact sexual responsiveness. For example, some individuals experience a firmer erection or increased lubrication when they are "giving" to their partner, than when they are receiving.

Schnarch notes that this is possible because "[ejmotional stimulation is often a more powerful determinant of genital fiinction and satisfaction than is touch" (p. 85). Sexual

10 complications in physical functioning result in the body's inability to receive and process

physical stimulation. This type of sexual difficulty can be attributed to various causes

(e.g., vascular diseases, hormones, prescription or illegal drugs, fatigue, stress, etc.).

Sexual complications that arise in the domains of thoughts and feelings also inhibit the

body's physical responsiveness, but the cause for the non-responsiveness is very

different. Thoughts and feelings give meaning to sexual experiences. Generally, there is

a relationship between the increase in unresolved issues that intrude during sex and a

distancing from an individual's sexual potential (Schnarch, 1997). Whatever type of

sexual hurdle that couples face, marriage and family therapists should possess the

knowledge and comfort level that enables them to help their clients address and resolve

these types of problems.

Despite the presumed importance of therapists' ability to address their clients'

sexual issues in the popular and professional literature, there has been a lack of formal

theoretical and empirical attention to this area. Two factors have been speculated in

previous research to affect therapists initiating sexuality related discussions with clients:

(1) therapist sexual knowledge and (2) therapist comfort level with sexual material.

Furthermore, since only minimal standards have been established for marriage and family

therapists (MFTs) formal training in human sexuality (AAMFT, 2002), it is reasonable to

question how therapists' comfort with sexual matters might be related to their knowledge

of sex. Very little research has been conducted in the area of mental health professionals' knowledge and comfort level with sexual material or how these two variables may

influence the therapist's likelihood of initiating sexuality-related topics in therapy

Additionally, there is no research on this topic as it pertains to the field of marriage and

11 family therapy. In Schnarch's work, Bowen theory is applied to sexual functioning in romantically committed relationships (Schnarch, 1997). In the present study Bowen

family systems was used as a framework from which the research questions are derived

(Kerr & Bowen, 1988).

The questions that were addressed in the current study are: (1) are MFTs initiating

therapeutic discussions on sexuality issues with their clients?; (2) how knowledgeable

are marriage and family therapists in sexually related matters?; (3) what is the therapist's

comfort level in initiating sexual discussions with clients?; and (4) how does therapists'

comfort with, and basic knowledge about sexually related topics, as well as graduate-

level sexuality education, supervision experience with sexuality issues, and clinical

experience with sexuality issues influence the likelihood of therapists initiating sexuality-

related discussions with clients? In addition, the researcher hypothesized that a

relationship exists between therapists' basic sexual knowledge and comfort with sexual

material. Since literature was lacking in this specific area, a broader scope of the sexual

knowledge and comfort levels of several different types of mental health professionals

were reviewed. Each of these variables is discussed below, but first the main tenets of

Bowen family systems theory are explained as it applies to the research questions.

Family Systems Theory

In Bowen family systems theory, the focus or unit of analysis shifts from the

internal processes of the individual to the relationships between the parts of a system as

they are defined relative to a particular context (Becvar & Becvar, 1997). In this theory,

linear causality does not exist; instead there is an emphasis on reciprocity, recursion, and

12 shared responsibility. "A" and "B" exist in the context of a relationship in which each influences the other. Family systems theory looks at the fimction of an individual's behavior in the broader context of the relationship. Thinking in terms of the function of a person's behavior indicates that humans are motivated by a process that is not contained

entirely within that individual, but, rather, within that individual's relationship system

(Kerr & Bowen, 1988).

Bowen family systems theory differs from general systems theory. Rather than

applying physical systems to the likeness of families, Bowen assumed that the family was

a naturally occurring system in and of itself (Kerr & Bowen, 1988). In other words, man

did not "create" the family system; instead the human family system developed fi-omth e

evolutionary process. The assumption made by family systems theorists is that the

principles that govern systems are already present in nature, and that humans simply

discover them. Therefore, Bowen postulated that humans and human families are driven

and guided by processes that are already determined by nature. For instance, the family

and the roles that individuals fulfill in the family were shaped and molded by the evolutionary process which emerged from the natural processes of survival.

The natural system that Bowen identifies with the family is termed an "emotional

system." The emotional system is identified as one of the core concepts in family

systems theory. Family systems theory makes clear the distinction between emotions and feelings. The emotionally-determined behaviors are described as behaviors that are innately present in humans. These behaviors are based on processes that are engrained in humans through the evolutionary process and go beyond thinking and feeling. Emotions, according to family systems theory, are not felt. Whereas feelings are identifiable when

13 they are feh, emotions are inferred through observing what people do and do not do in a given situation. For example, without much thought a parent will shield or protect their child from a dangerous situation, while at the same time putting themselves in harms way if necessary. The instant demonstration of protectiveness by the parent is an instinctual reaction, or according to Bowen, an emotion that has been hardwired through the evolutionary process that is executed instinctively, without/ee/mg.

Family systems theory identifies three systems (emotional, feeling and

intellectual) to be key influences on human functioning and behavior. The intellectual

system makes it possible for humans to observe nature objectively. Objectivity in observation is important to family systems theory because nature itself is neutral. With objectivity humans are able to identify the process of interrelated events within nature, without assigning judgment to that process. While the potential for objectivity is

(theoretically) present in the intellectual systems' of humans, it is usually overtaken by one's emotional and feeling processes. Consistent with the concepts of family systems theory, the emotional, feeling, and intellectual systems mutually influence one another.

Family systems theory characterizes the family as an emotional unit or emotional field. Within this unit, people are bom into and occupy functioning positions. The functioning positions operate in reciprocal relationship to one another. These fimctioning positions have an influence on various aspects of a person's life. Likewise, the emotional atmosphere generated by a family, influences the emotional functioning of each person.

Although the emotional field is not a tangible object that can be seen, the presence of the emotional field is inferred by the predictable ways people behave in reaction to one another. Conceptualization of this interplay between what is occurring within the

14 individual and the fimctioning position of that individual in his or her most emotionally significant relationship system is a very important aspect of systems thinking (Kerr &

Bowen, 1988). It should be noted that in times of stress, functioning positions are pushed toward extremes.

Thus far, concepts of Bowen family theory have been discussed as they apply to the family. However, these concepts are applicable to all of the systems in which an individual participates. Just as family members can become reactive to other family members or topics, therapists possess the same potential for reactivity. When a person is emotionally involved in a situation or subject, the thinking response can be overwhelmed by intense feelings and emotional responses (Kerr & Bowen, 1991). Emotional reactivity has been evident in both family members and therapists when the subject of sexuality is addressed (McConnell, 1976; Schnarch, 1997). Sometimes people are aware that their thinking has been influenced by their feelings and emotions, but more often than not, the

subtleness of the processes involved precludes awareness (Kerr & Bowen, 1991). It is obviously problematic if therapists are unaware of the influence of their own feelings and emotions about sexuality issues that need to be addressed with clients.

According to Bowen family theory it is difficult for therapists to be helpful to families, when feeling and emotional responses to the family interfere with one's awareness of the relationship process. In other words, therapists that become anxious in the presence of anxious families not only lose sight of the relationship process but also perpetuate symptoms of the problem within the system.

Another key concept for the relationship process in family systems theory is differentiation of self Differentiation of self is defined as, "[the] difference between

15 people in proportion of life energy prone to be invested and bound in relationships" (Kerr

& Bowen, 1991, p. 68). In pooriy differentiated individuals much of their energy is relationship-bound. Individuality is less developed and togetherness needs are stronger.

Individuals with lower levels of differentiation are usually easily triggered into intense

emotional reactions. The inverse is true for individuals with higher levels of

differentiation. While highly differentiated people may respond to others on an

emotional and feeling level, they still possess the capacity to process these responses on

an objective level: "[t]he characteristic that best describes the difference between people

at various points on the scale is the degree to which they are able to distinguish between the feeling process and the intellectual process" (Kerr & Bowen, 1991, p. 97).

The differentiation level of the therapist is an important factor in the therapeutic

relationship process. When people feel threatened, emotions and feelings serve as a trigger to take action to relieve the threat. If a therapist feels threatened by discussing

sexuality issues with clients, more of the therapist's energy will be invested in reducing that anxiety. Thus, when a poorly differentiated therapist is working with a family that has anxiety about sexuality-related topics, both the family and therapist will use their energy to relieve the family's anxiety. According to Kerr and Bowen (1991), "[t]he lower the level of differentiation, the less people's tolerance for anxiety in themselves and others and the quicker they are to do things to relieve it" (p. 79). In most cases, the relieving of anxiety around sexuality issues in therapy is synonymous with avoiding sexuality-related discussions. Poorly differentiated therapists wouldn't initiate or facilitate sexuality-related discussions if they or their clients were uncomfortable with the subject matter. Unfortunately, as differentiation decreases, relationship needs grow

16 sti-onger, and emotional reactivity intensifies, the level of anxiety progressively increases.

In other words, as individual anxiety increases it triggers more of the same in others.

Therefore, undifferentiated therapists are at risk for emotional reactivity and taking on the anxiety of the family and in return, creating more anxiety and reactivity in the family. On the other hand, a differentiated therapist is able to maintain a nonanxious presence in the face of anxious others (Friedman, 1991).

Attempts to achieve a higher level of differentiation is to increase one's capacity for emotional detachment or neutrality. Gaining more emotional detachment and

neutrality are dependent on a new way of thinking. These changes are reflected in the

therapist's ability to be in emotional contact with a difficult, emotionally charged

problem without feeling compelled to fix the problem, lecture about what should be done,

or pretend to be detached by emotionally isolating his or herself (Kerr & Bowen, 1991).

Emotional neutrality and detachment address the ability of the therapist to be in contact

with a problem but not become part of the problem. These elements are reflected in

therapists' ability to develop more awareness of, and control over their emotional

reactivity, be calm about the process between others, and be cognizant of all the

emotionally-determined sides of an issue (Kerr & Bowen, 1991). According to Bowen,

clients can only differentiate to the level of the therapist. Therefore, in Bowen's model

there is emphasis on the self-development of the therapist. Maintaining a non-anxious

presence, being objective and/or promoting differentiation in others is connected to the

differentiated self of therapist (Friedman, 1991).

As mentioned previously, anxiety is infectious. As people react based on anxiety,

they are less tolerant of one another and more irritated by differences. The more anxious

17 an individual becomes, the more they become convinced that their way is the "right" way

and therefore attempt to get others to follow. The level of differentiation of individuals is

a factor in how they respond to anxiety. If therapists respond to anxiety with more

anxiety, then they cannot be helpful to their clients and may even make the symptoms

worse or more intense (Friedman, 1991).

Differentiation of self is one of two key concepts used by family systems theory

to explain level of fimctioning. The second concept is chronic anxiety. Anxiety and

emotional reactivity are often interchangeable terms in family systems theory:

"[ijncreased anxiety is manifested in increased degrees of various types of emotional

reactivity" (Kerr & Bowen, 1988, p.l 13). Thus, increased levels of anxiety are

observable through increased emotional reactivity.

Family systems theory makes a distinction between acute and chronic anxiety.

Acute anxiety is described as a response to real threats and is time-limited. Most people

are successful at managing acute anxiety. Generally speaking, chronic anxiety occurs in response to imagined threats and is not experienced as time-limited. Chronic anxiety is conceptualized as "a system or process of actions and reactions that, once triggered, quickly provides its ovm momentum and becomes largely independent of initial trigger stimuli" (Kerr & Bowen, 1988, p.l 13). Chronic anxiety is the emotional and physical reactivity responses that are automatic rather than chosen (Friedman, 1991).

Although differentiation and chronic anxiety are separate concepts in family systems theory, they are not mutually exclusive. As therapists increase their level of differentiation, their level of chronic anxiety decreases. One reflection of increased differentiation is the therapist's ability to be a non-anxious presence. Maintaining a non-

18 anxious presence facilitates a decrease in the therapist's as well as the family's chronic

anxiety. As the level of chronic anxiety decreases, therapists' and families' openness for

change increases, thereby reducing emotional reactivity. Additionally, this new way of

being and processing information lessens the threat and anxiety around previously

avoided subjects. Increased differentiation and a decrease in the level of chronic anxiety,

invite discussion around previously avoided topics with the hopes of learning something

new about the self

In summary, while it seems reasonable to suggest that therapists' level of comfort

with sexual issues influence therapists' willingness to initiate sexual discussions, no

previous studies had been conducted in this area. Bowen family systems theory supports

the notion that reduction in anxiety may increase flexibility and openness. Thus, it was

hypothesized in this investigation, that therapist comfort level with sexuality issues would

have a direct, positive influence on therapist sexuality discussions with clients; i.e., the

greater the comfort level of therapists, the greater the likelihood that therapists will

initiate sexuality-related discussions with their clients.

Additionally, Bowen family systems theory encourages objectivity, which is only possible when the intellectual system is not overridden by the emotional or feeling system. Therefore, as therapists increase their sexual knowledge, their intellectual advancement in the area should increase their willingness to initiate sexual discussions with clients. It is through objectivity and intellectual reasoning that humans are able to achieve greater degrees of differentiation, which inevitably creates more flexibility in dialogue. Thus, it was hypothesized, that therapist sexual knowledge would have a direct, positive influence on therapist sexuality discussions with clients.

19 Therapist Knowledge About Sex

In 1989, The Kinsey Institute tested the basic sexual knowledge of a statistically representative group of 11,974 American adults (Reinisch, 1990). The poll, which used the consisted of 5 multiple-choice questions and 13 true/false questions, was conducted during face-to-face interviews. The results of this study indicated that the majority of

Americans were misinformed about a variety of sexual matters. With 55 percent of the sample failing the test, only 4.5 percent received a grade of "B" or better. It is clear from these resuhs that the American public is either not exposed to, or doesn't retain accurate sexual information. When asked where they received their sexual information while growing up, none of the respondents indicated that they had received that information from a counselor or therapist. On the other hand, when asked where they would go for answers now, 7% indicated they would seek that information from a counselor or therapist.

One of the main factors found to influence a person's ability to pass The Kinsey

Institute/Roper Organization National Sex Knowledge Test, was the respondents source of sex information throughout his or her life. More individuals who passed the test received sexual information while growing up from the places most likely to provide factual information (e.g., books, medical doctors, etc.). Those individuals, who failed, were more likely to say that they had no source at all.

As adults, the people who passed the test would also consult sources most likely to provide accurate infonnation about sex. For instance, 39% of those who passed said they would refer to a book, compared with only 22 % of those who failed. Those who

scored passing grades were also twice as likely to seek information from a therapist or

20 counselor. Given the role therapists can play in educating the public, it seems imperative that they be knowledgeable about sex and sexuality.

Kirkpatrick (1980), in his survey of counselors' (N=160) beliefs about what sexual information would be important to a beginning counselor, found that respondents assigned high importance to factual knowledge about contraception, abortion, sexually transmitted infections, puberty, as well as the anatomy and physiology of human reproduction. Likewise, assistance with decisions about unplanned pregnancies, virginity, and one's first intercourse experience were also rated as important. Several items designed to measure helping clients make adjustments to their sexual personalities or lifestyles were also rated highly. These items addressed the ability to discuss and assess sexual dysfunctions, same-sex attractions, sex-role equality, and partner adjustment to variance in sexual behavior patterns. In addition, Kirkpatrick (1980) found that the "[ajbility to discuss clients' sexuality as easily as other concerns" had the highest mean response. Given these findings, Kirkpatrick (1980) concluded that knowledge of sexuality should be required of covmselors in training and outlined priorities for instruction in sex counseling.

Mental health professionals are expected to be knowledgeable about a vast array subjects. Ethically, a therapist must provide competent help when working with clients.

While past studies have acknowledged the increasing occasion that therapists find themselves in the role of a sex educator (McConnell, 1976) and other authors have suggested that marriage and family therapists are the logical choice to provide sex education to clients (Vesper & Brock, 1991). Yet, these same therapists may have no formal sexuality training and may have less factual information than clients (Weerakoon

21 & Stiemborg, 1996). Though clients expect that mental health professionals will be

knowledgeable about sexuality, this is not always the case (Nathan, 1986).

In a study designed to investigate the assumption that counselors require specific

fraining in sex counseling, McConnell (1976) suggested that clients seeking sex

counseling "had about an equal chance of encountering either a sex illiterate or, at best, a

minimally informed individual" (p. 187). The conclusion drawn from the author is based

on a sample of 36 master's level counselor trainees, none of whom had received specific

training in sex counseling, despite the fact that each had completed at least one semester

of practicum as well as theoretical courses. Results from the Sex Knowledge Inventory

(McHugh, 1950) that was administered to the subjects raised serious concerns about the

sexual competency of the group. The finding that counselors are often ill prepared to

deal with human sexuality has been replicated in other studies (Christensen et al., 1977;

Kirkpatiick, 1980).

At an annual refresher course in family medicine, attendees were asked to

complete a 152-item questionnaire about human sexuality. Family physicians (N=104) at

the conference completed the questionnaire, which was a compilation of the Sex

Knowledge and Attitude Test (SKAT; Lief & Reed, 1972) and questions designed by the

investigators (Driscoll et al., 1982). To create a comparison group for the study, the

questionnaire was also administered to 175 sophomore medical students after the

completion of a human sexuality course. Based on the results of the study, the authors concluded that the physicians did not recognize common sexual mythology as fallacy and

scored no higher than the average sophomore-level medical student on overall knowledge about sex (Driscoll et al., 1982). Additionally, the physicians in the study who routinely

22 took sex histories from patients, scored the same as physicians that never took sex histories. Based on these findings, the authors conclude that family physicians lack adequate sex knowledge to be helpftil to their patients. Though a majority of physicians endorsed formal sexuality education as a tool to increase comfort levels when taking sexual histories and addressing sexual issues, only 32% reported ever taking such a course.

Taken together, the results of this suggest that most health professionals lack sufficient preparation to be considered competent in addressing sexuality issues.

Furthermore, the literature underscores the importance of mental health professionals' need to maintain an accurate knowledge base about sex and sexuality. What is not clear from the review is the identification of factors that effectively increase therapists' knowledge about sex and sexuality issues. These findings highlight the need for sexuality training for mental health professionals, and including training of marriage and family therapists. Thus for the present study, it was hypothesized that graduate-level sexuality education, clinical experience addressing sexuality issues, and positive supervisory experiences addressing sexuality issues, would all have a direct influence on therapists' sexual knowledge. Although the study performed by Driscoll et al. (1982) found the sex knowledge of physicians who routinely took sex histories to be equivalent to the sex knowledge of physicians that never took sex histories, it was hypothesized that therapists' sexual knowledge would have a direct, positive influence on therapists initiating sexuality-related discussions with their clients.

23 Therapist Sexuality Education

For the most part, therapists have grown up in the same culture as clients.

American culture is often negative about sexuality or is sexually silent (Stayton, 1998).

Without proper training, a therapist may be perceived as being a "expert," and yet know

less, and be more confiised and secretive about sex than the client. Even the professional

who has adequate sexual knowledge may be unable to be of help to a client, because of

his or her own anxieties about sexuality (Cross, 1991).

Comprehensive sexuality education affirms sexuality, promotes sexual health, and

strives to prevent unsafe sexual practice such as unprotected coitus. This approach

broadens the fraditional approach to sex education, which focuses on reproductive

biology, sexually transmitted infections, and introduces sexuality as a fundamental

component to an overall positive self-esteem (National guidelines task force, 1996). The

comprehensive approach extends beyond these elements and attempts to help people

embrace their sexuality, beyond the realms of the act of sexual intercourse.

Additionally, this approach encourages people to process the information beyond the

cognitive component.

In addition to the presentation of factual information, sexuality education should

also incorporate training on the affective and behavioral components of sexuality,

because when initiating a topic laden with strong emotions, judgments, morals, and

values, offering only factual information does not help the clinician work through his or

her own attitudes, values, and comfort level with sexual topics (Stayton, 1998). In other

24 words, mental health professionals must better understand their own sexuality as a first step to aiding others in coping vsdth theirs (Christensen et al., 1977; Fyfe, 1980;

Kirkpatrick, 1979).

Considering tiie relative status and power differential between therapists and clients, therapists have to consider to what extent they may impose their own values on clients. "Clinicians actively engaged in the delivery of mental health services must at some point come to terms with ethical issues to best protect the rights of clients, as well as to achieve a resolution of personal conflict over such issues" (Morrison, Layton, &

Newman, 1983, p. 78). Likewise, it has been suggested that sexuality educators' feelings and attitudes towards sexuality influences teaching effectiveness (Graham & Smith,

1984). There is also the risk that students may assimilate their teacher's sexual feelings and attitudes (Graham & Smith, 1984). It is possible that this type of assimilation could occur in the therapy room. Thus, in order to function competently, therapists need to become aware of their own attitudes, feelings, and judgments about all areas of sexuality, have a basic body of knowledge about sex and sexuality, and possess the skills to address the sexual concerns of the client (Stayton, 1998). If therapists fail to do this, there is danger of undeclared values guiding both the therapists' behavior as well as the behavior of clients (Renshaw & Ryan, 1986). Through differentiation of self, therapists learn to tolerate attitudinal differences and reexamine their own anxiety around sexuality.

Many believe that Sexual Attitude Reassessment (SAR; Theodore & Cole, 1973) seminars serve as a useful tool for therapists and educators to explore and clarify their values and attitudes (Ducharme & Gill, 1990; Stayton, 1998). The purpose of these seminars is to visually expose respondents to diverse and explicit sexual materials. The

25 material and the respondents' values and anxieties are then processed in small groups.

The intimacy and safety of the small group format encourages respondents to make personal reflections on their reactions to the presented materials. An additional hypothesized benefit from the SAR seminars is increased comfort with sexuality issues.

Desensitization is one of the recognized tools for increasing sexual comfort (Graham &

Smith, 1984).

The SAR concept of desensitization is similar to Bowen family systems theory concept of differentiation. Bowen believed that as a therapist (or family member) increases their level of differentiation, he or she reduces his or her personal level of chronic anxiety as well as the level of chronic anxiety in the family. The process of decreasing the level of one's chronic anxiety is thought to be learned.

An intellectual decision to engage people and situations one prefers to avoid and a decision to tolerate the anxiety associated with not doing things one normally does to reduce anxiety in oneself in those situations can, if done repeatedly over a long period of time, lead to a reduction in one's level of chronic anxiety. This is anxiety reduction based on learning rather than on emotional or physical distance. (Kerr & Bowen, 1991, p. 131)

Bowen repeatedly stressed the importance of the therapist to maintain a non-anxious presence during stressful or anxious times in session.

Clients can derive a variety of benefits from marriage and family therapists who are sexually educated. For example, specialized counseling skills and comfort in addressing sexual issues by therapists, may influence the safer sex practices of clients.

This may help decrease the spread of sexually transmitted diseases and unintended pregnancies in some groups. The quality of life over the life span may also be improved when therapists are supportive of continued acknowledgement and expression of the

26 sexual dimension of the self (Bonner & Gendel, 1985). One professional goal is to work with clients from a systemic framework that encompasses the external and internal influences on clients' sexual development. A systemic approach to therapy can create a safe space for clients to discuss their sexuality, and enable clients to integrate this aspect of their lives into a healthier self-identity.

In sum, research indicates the importance of sexuality education for mental health professionals. It is through education that therapists become aware of the affective, behavioral and cognitive components of sexuality. Sexuality education was noted as a factor for increasing comfort with discussion of sexual matters (Graham & Smith, 1984).

The majority of the physicians in Driscoll et al. (1982) study indicated formal sexuality education would be an effective tool to increase their comfort level with sexual matters and willingness to address sexual issues with patients.

Sexuality education doesn't only occur in the classroom, individuals also learn from experience. Based on the concepts taken from SAR seminars, as people are exposed to sexual material their comfort level tends to increase. For therapists, exposure to sexual issues may occur in session as well as in a formal education setting. Whether exposed to sexual issues in the classroom or in session, therapists are expected to address such matters with a sense of comfort and openness. Working toward a higher level of differentiation, therapists' anxiety levels will decrease, resulting in a greater comfort level with topics related to sex (Schnarch, 1997). Thus it was hypothesized, that graduate-level sexuality education, clinical experience addressing sexual issues and positive supervisory experience addressing sexual issues would have a direct influence on therapists' comfort level with sexual matters.

27 With the present study focusing specifically on marriage and family therapists, the following section will review the American Association for Marriage and Family

Therapy's (AAMFT) training standards for sexuality issues. These standards are developed by the Commission on Accreditation for Marriage and Family Therapy

Education (COAMFTE). This section examines the amount of formal sexuality education

offered to MFTs in accredited graduate programs.

Marriage and Family Therapists Sexuality Education

The American Association for Marriage and Family Therapy (AAMFT) is the

organization responsible for establishing the credentials that are necessary in order to be

recognized as a clinical marriage and family therapist. Founded in 1942, the AAMFT has

a commission that establishes the standards for graduate education and training within the

field of marriage and family therapy (AAMFT, 2001, Overview section, para 2). As

noted in the preamble of Version 10.0 of the Standards, the established standards are

considered a minimal requirement for quality training (AAMFT, 2001, standards

section). Accredited programs are encouraged to include other requirements that would

enhance the education and training of their students.

The accreditation standards developed by the COAMFTE differentiate between

the standard curriculum for master level students and the curriculum for doctoral level

students. Students entering an accredited Marriage and Family Therapy (MFT) program

at the doctoral level are expected to meet the curriculum requirements for master level

students, as well as the required components of the doctoral curriculum. Since many

doctoral MFT students bring with them master's degrees in other fields, they are

28 required to complete the required masters levels courses in addition to the doctoral level

courses. Students entering a doctoral MFT program with a master's degree in MFT from

an accredited program will have already met the masters level curriculum requirements

(AAMFT, 2001, standards section).

Within the current COAMFTE standards, the topic of sexuality is addressed at the

masters level. The standard (masters level) curriculum is divided into six components:

Area I addresses theoretical knowledge; Area II focuses on clinical knowledge; Area III

concentrates on individual development and family relations; Area IV addresses

professional identity and ethics; Area V focuses on research; and Area VI is designated

for additional learning. Of the six areas that comprise the master's level curriculiun, the

clinical knowledge section (Area II) is the only section that specifically addresses

sexuality issues (AAMFT, 2001, standards section).

The COAMFTE standard 320.01 states that students are required to complete a

minimum of four Standard Didactic Units (SDUs) from the clinical section (Area II).

One SDU is equivalent to a three-credit course within a school system that operates on

semesters. In other words, MFT students are required to take a minimum of foiu- three-

credit courses that meet the outlined Area II standards training (AAMFT, 2001, standards

section).

Relating specifically to the sexuality training of MFT students is the COAMFTE

standard 320.06 which states, "Area II will include content on issues of gender and sexual

functioning, sexual orientation, and sex therapy as they relate to couple, marriage and

family therapy theory and practice" (AAMFT, 2001, standards section). The requirements outlined in standard 320.06 ensure that MFT students are exposed to some

29 level of sexuality education and/or training. Since the other five standards listed in Area

II include many other topics that must be covered in the standard curriculum, it is unclear how much time is actually devoted to sexual issues in each of the accredited programs.

The amount of time dedicated to sexuality education and training in MFT programs is not regulated, other than specifying that sexuality issues must be addressed. Therefore, it is conceivable that some accredited programs could have a three-credit course devoted solely to sexuality issues, while another creates space in a contemporary issues course for the discussion of sexuality issues at one of the class meetings.

Although there is not a requirement in the doctoral curriculum for a sexuality component, all doctoral students are required to fulfill the standards outlined at the master's level. Therefore, it is assumed that all current MFT students will have some level of formal education in sexuality issues as they pertain to therapy. This, however, cannot be assumed for all AAMFT clinical members. As Marriage and Family Therapy has progressed as a field, so has its standard curriculum requirements. Version 8.1 of the accreditation standards, written in 1994, was the first version to include a standard devoted solely to addressing sexuality issues in the curriculum. Standard 401.30008 in version 8.1 states, "[pjrograms will expose all students to issues of sexuality as they relate to marriage and family therapy, theory and practice. Course content will include sexual orientation and sexual functioning" (p. 15). Prior to the 1994 standard, version 7.0 included a sexuality component in the curriculum under the subheading "Gender Issues" in Area III. Version 6.0, adopted in 1984, briefly mentioned the need for "relevant" course work in "human sexuality" under the heading of "Individual Development."

30 Therapist Comfort with Sexual Matters

Research has consistently linked sexual knowledge to increased sexual awareness and an ability to work comfortably with clients who have sexual concerns (Anderson,

1986; Bonner & Gendel, 1989; Driscoll et al., 1982; Kirkpatrick, 1980; Landis et al.,

1975; Yallop & Fitzgerald, 1997). The relationship between sexual knowledge and comfort levels with sexual material will be reviewed in this section.

Anderson (1986) suggested that therapists gain self-confidence, comfort and competence with sexually related materials as a result of their increased knowledge about sexual matters. He identified four overlapping stages that students characteristically progress through as they become more comfortable with sexual material. These stages are: (1) an examination of their views and concerns about their own personal sexual issues; (2) an increasing awareness and appreciation of problems and emotional reactions as the clients experience them; (3) a new freedom in discussing sexual matters with colleagues and friends; and (4) an awareness of a new level of comfort with clients and increased willingness on the part of their clients to share sexual material. Anderson hypothesized that therapists-in-training progress through these stages as a result of becoming more affectively, cognitively, and behaviorally knowledgeable about sex.

Supporting the idea that both sexual knowledge and comfort with sexual material are integral components to therapists' ability to help clients with sexual matters, Nathan

(1986) developed a four-level hierarchy of psychologist expertise with human sexuality.

Level 1 is the ability to be comfortable hearing and eliciting sexual material; Level 2 is the ability to assess the diagnostic significance of sexual behaviors and symptoms; Level

3 is the ability to evaluate sexual problems in order to intervene or refer; and Level 4 is

31 the ability to treat sexual problems and/or to teach and do research in the field. Therefore the most basic level of expertise, which Anderson considers necessary to all clinical psychologists, is the ability to be comfortable hearing sexual material. Nathan hypothesized that it is usually exposure to sexual information that propels psychologists toward higher levels of expertise and comfort. She contends that therapists-in-training could graduate with Level 1 expertise and continue to progress to higher levels through interactions with clients and supervisors, based on their established ease and comfort with the material. On the other hand, if therapists are not initially exposed to sexual information, then it is reasonable to assume that higher levels of comfort will not be achieved.

As researchers set out to measure the sexual comfort of various populations,

Graham and Smith (1984) designed a study to operationalize the concept of sexuality comfort. Thirty-two high school and college sexuality educators were interviewed in regard to their thoughts about sexuality comfort. Subjects' answers to the 19 interview questions were transcribed and coded. The researchers concluded from the results that teachers who were more anxious about communicating sexual information were less effective educators (Graham & Smith, 1984). Thus, while knowledge is a key component to being a sexuality educator, the researchers suggested that comfort with sexuality material is another essential requirement. Subjects in the study unanimously agreed that possessing information about sexuality does not ensure one's ability to teach it to others.

The emphasis in the study was that knowing facts about sexuality is not equivalent to being comfortable with what one knows. The authors included several suggestions for

32 increasing sexuality comfort, one of which was to increase one's knowledge base with

sexuality matters (Graham & Smith, 1984).

In a pedagogical study, Graham and Smith (1984) recommend that sexuality

educators participate in a "methods" course in sexuality education that focuses solely on

increasing sexuality comfort. In addition to gaining factual sexuality information,

educators explore their sexual feelings and attitudes; respect and acceptance of others;

sexual practices; and communication skills. These authors demonstrated that cognitive,

affective and behavioral responses to sexuality was linked to an increase in sexuality

comfort (Graham & Smith, 1984).

In a study that examined the sexual comfort levels of occupational therapists, the

researchers (Yallop & Fitzgerald, 1997) found that most of the subjects expressed feeling

uncomfortable and unprepared when dealing with sexuality Yallop and Fitzgerald (1997)

concluded from their study that many of these therapists do not understand their own

sexuality, and so would be uncomfortable initiating conversations about their clients'

sexuality. Respondents in this study (Yallop &. Fitzgerald, 1997) identified knowledge as

the major contributor to comfort with sexuality-related issues and the factor that would

most increase tiieir comfort with sexuality. The therapists in the study acknowledged an

awareness of one's own values and beliefs about sexuality and how each impacts relating

with clients. It has been postulated that even the professional who has adequate sexual

knowledge may be unable to be of help to a patient or client because of his or her ovm

anxieties about sexuality (Stayton, 1998). Therefore, knowledge alone is considered

inadequate preparation for working with clients around sexuality issues.

33 Taken together, the results of this review indicate that therapists' sexual knowledge is positively associated with therapist comfort with sexual matters. Thus, it was hypothesized that therapists' sexual knowledge would have a direct, positive

influence on therapist comfort with sexual matters. In other words, as therapists' sexual

knowledge increases so will their comfort level with addressing sexual matters with

clients.

Summary

Chapter II reviewed the literature to date in the area of therapist sexual knowledge

and comfort with sexual material by examining the influence of these variables on client

interactions. The literature suggests suggested that these two variables might impact

therapists' sexuality discussions with clients. Across all sections of this review it has

been noted that there is no research that investigates variables influencing therapists'

sexuality discussions with clients. While there is some research that examines therapist

sexual knowledge and related sexual comfort, there is no research that specifically

pertains to marriage and family therapists. Chapter III presents the research design,

instrumentation and hypotheses that were used to conduct this investigation.

34 CHAPTER III

PROCEDURES

Introduction

Chapter III outlines the research methodology used in this sttidy. It begins with a restatement of the problem, followed by descriptions of the sampling procedures, research design, data collection procedures, and instrumentation used in this investigation. Next, the specific hypotheses that were tested are described, as are the statistical analyses of the investigation. A summary concludes the chapter.

Restatement of the Problem

The aim of the present study was to determine: (1) how therapist sexual knowledge influences therapist comfort with sexuality issues; (2) what direct influence graduate level sexuality education, positive supervisory experience with sexuality issues, and clinical experience with sexuality issues may have on therapist sexuality knowledge and comfort with sexuality-related issues; and, (3) how these variables influence therapists' likeliness to initiate sexuality discussions with clients.

Description of Sampling Procedures

Three hundred and fifty surveys were mailed to a random sample of clinical members of the American Association for Marriage and Family Therapy (AAMFT) chosen randomly from a nationwide membership database. Only AAMFT clinical

35 members participated in the study because the focus of this study was on the training and practices of marriage and family therapists.

Clinical members in AAMFT have met the minimum requirements established by

AAMFT for classification in this category. Specifically, clinical members meet the following requirements: (1) have a graduate-level degree in marriage and family therapy or a related mental health discipline from a regionally accredited institution, (2) have successfully completed 11 courses in theory, practice, human development, research and ethics, (3) have had a minimum of 300 supervised clinical practicum hours during their graduate training, (4) have had a minimum of 1000 hours of direct client contact hours and 200 hours of supervision, and (5) have agreed to abide by the AAMFT Code of

Ethics (AAMFT, 2001, Clinical Membership section, para 1).

Based on the criteria for clinical membership, it can be assumed that all respondents will have a degree in MFT or a related field from an accredited program.

Therefore, based on the standards developed for accredited programs it can be assumed that respondents: will have been exposed to family systems, will have some exposure to

sexuality education in their graduate program as expressed in the accredhation standards,

will have had a minimum of 1000 direct client contact hours and a minimum of 500

supervision hours. Data was collected over a two-month period.

Procedures

All of the procedures and instruments for this study were approved by the Texas

Tech University's Institutional Review Board for Protection of Human Subjects (see

Appendix A). Based loosely on the Tailored Design Method, a four-contact sequence

36 consisting of a pre-notice letter (see Appendix B), cover letter (see Appendix C) and questionnaire (see Appendix D), reminder postcard (see Appendix E), and replacement questionnaire (see Appendix F) was planned to be sent to all respondents (Dillman,

2000).

Initially, respondents received a letter in the mail indicating that they had been randomly selected to participate in the study, based on their affiliation with the AAMFT.

The letter informed respondents of the arrival of a survey during the following week.

Research has consistently indicated that prenotice would increase response rates to mail surveys (Dillman, 2000). Dillman (2000) suggested the use of a prenotice letter versus a prenotice postcard because it takes approximately 20 seconds to get an event into long- term memory. In comparison to a postcard, a letter takes longer to open and is able to provide more information about the study as well as any accredited affiliations. In the case of the present study, letterhead stationary was used to give credence to the researcher and build trust with the respondents. Those clinical AAMFT members that prefered not to participate in the study were encouraged to contact the researcher, either via email or telephone, so that a survey was not mailed to them. All subjects that did not contact the researcher to indicate otherwise received the survey in the mail within ten days of receiving the pre-notice letter.

As suggested by Dillman (2000), questionnaires were mailed out no later than the following week. Subjects received the survey in the mail with a cover sheet that introduced the study and researcher, and provided instructions for completing and returning the survey. Additionally, the cover sheet provided reassurance of respondents' confidentiality. This mailing also included a self addressed stamped envelope for the

37 return of the survey. As stated on the cover sheet, completion and retum of the survey served as consent for participation in the study. A unique identification number was printed directly on each questionnaire. The identification number was to ensure that replacement siu^eys would be sent only to non-respondents. This eliminated confiasion with respondents and the possibility of respondents returning two completed questionnaires (Dillman, 2000). Respondents were asked to retum the survey within 10 days.

A postcard was sent to all respondents 14 days after the mailing of the survey.

The postcard served as both a thank you for those who had responded and as a friendly reminder for those who had not. Research has indicated that most people who answer questionnaires do so almost immediately after they receive them. Therefore, the timing of the postcard was to show appreciation to those people while reminding others to do the same before the questionnaire was misplaced or forgotten (Dillman, 2000). Using a postcard for this third contact was a deliberate choice. Dillman (2000) suggests that this contact should contrast with the prenotice letter because repeated stimuli has shown to have less effect than new ones. The prenotice letter was intended to be longer so as to be stored in long-term memory. The reminder postcard, on the other hand, was intended to jog respondents' memory.

The fourth and final contact planned was a replacement questionnaire (Appendix

D). Using the identification numbers on the retumed surveys, replacement surveys were to be sent to respondents that had not yet completed the survey. Dillman (2000) suggests that the letter accompanying the replacement survey possess a tone of insistence. This letter serves as reinforcement of the messages contained in the three previous contacts,

38 specifically, that the respondent's data is important to the success of the survey. This mailing was to be sent out 2 weeks after the mailing of the reminder postcard. It is essential that a replacement survey was included with the follow-up letter because the time elapsed between this mailing and the initial mailing of the survey increased the probability that the original survey had been misplaced or discarded.

Instmmentation

In total, respondents answered 48 questions on the survey. The survey consisted

of demographic questions, questions designed by the researcher to assess sexuality

discussions, as well as comfort with addressing sexuality issues, and a portion of the

Sexuality Knowledge and Attitude Test (SKAT; Lief & Reed, 1972) to assess therapist

sexual knowledge. Many of the non-demographic questions were in Likert-type format,

except for the questions from the SKAT which were in tme/false format.

The instruments for this study are presented below. The selection of instruments

was based on the test's relationship to the variables under investigation, ease of

administration, and soundness of their psychometric properties compared with other

instruments. In some cases, questions were developed because an appropriate measure

did not exist. Six measures ranging from 5 to 34 items were used to assess individual

characteristics of the respondents in the sample (see Table 1). The mean score for each

endogenous variable was used in the analyses. Reliability for these scales were measured

by Cronbach's alpha. A summative score was used for the exogenous variables in the

analyses; therefore a reliability score was not calculated for these scales. A more detailed

description of each scale follows.

39 Table 1: Initial Scale Names, Example Questions, and Reliability Scores

Scale Name Number of Example Question Cronbach Questions alpha

Sexuality Education 7 I have attended workshop(s) on sexuality. N/A

Clinical I regularly work with clients presenting Experience 5 with sexual concems. N/A

Supervision I have discussed sexuality issues with Experience 6 a supervisor during my graduate training. N/A

Basic Sex The use of the condom is the most reliable Knowledge 34 of the various contraceptive methods. .54

Sexual Comfort 15 I communicate effectively about sexuality. .86

Sexuality I routinely assess for and initiate therapeutic Discussions 9 conversation on sexual dysfunction. .90

40 Sexuality Education scale

The Sexuality Education measure was developed to assess the types of sexuality education received during or after graduate school. This self-report measure consists of seven items. Items ask specific questions about the level of sexual education respondents have received (see question 7 in Appendix D). For example, respondents were asked if they had a graduate course in human sexuality and if they have attended workshop(s) on sexuality. One point was given for each indication of participation in a sexuality

education venue. Higher scores on this scale indicate more sexuality education.

Clinical Experience scale

The Clinical Experience measure is a 5-item self-report measure, developed to

assess the degree of therapist clinical experience with sexuality issues (see question 8 in

Appendix D). Again, higher scores indicate more clinical experience with sexuality

issues.

Experience in Supervision scale

The Experience in Supervision measure is designed to assess the presence or

absence of a supervisory experience in which sexuality issues were discussed. The

Experience in Supervision measure consists of five questions (see question 9 in Appendix

D). Higher scores on this scale indicate greater experience in discussing sexuality issues

with a supervisor.

41 Sex Knowledge and Attittide Test rSKAT)

The SKAT was chosen as an instmment for this study after an extensive review of hterature and other available sexual knowledge instruments. Unforttmately, the number of measures available assessing sexual knowledge is relatively small (Davis, Yarber,

Bauserman, Schreer, & Davis, 1998; Schumm, 1990). The pool of appropriate measures becomes even smaller when the target population is therapists. Currently, there are no sex knowledge measures designed specifically to test the sexual knowledge of therapists or other graduate-level professionals. Based on these findings, the present researcher determined that the SKAT would serve as the best available measure for the basic sex knowledge variable in the current study.

The SKAT is a pre-existing scale used to assess sexual attitudes, knowledge, and level of personal sexual experience (Miller & Lief, 1979). Since its publication in 1972, the SKAT has been administered to thousands of students and health professionals as one of the only instmments on sexual knowledge and attitudes in existence. Lief and Reed

(1972) assembled a pool of 180 items drawn from three sources: a survey of relevant literature, clinical experience, and socially controversial sex-related topics. This preliminary compilation was administered to 834 students in three countries. The revised version was completed in the late 1960s and completed by 2,274 medical students. The present form of the SKAT (1972 version) was derived after statistical analyses of this second round of data.

The 1972 version of the SKAT is comprised of an attitudes subscale, a knowledge subscale, and two subscales that assess background data and sexual experience. The knowledge subscale of the SKAT contains 71 tme/false items. Twenty-one of the

42 true/false items were developed for their teaching value. And used for purposes of classroom discussion. These items were not germane to the constmcts of interest in the study and were therefore omitted. The remaining 50 items comprising the knowledge subscale of the SKAT were designed for potential use in research. These items have an

item difficulty ranging from .25 to .75 and point biserial correlations of .30 or greater.

The raw correct mean score of the 50-item sex knowledge test based on a sample of 851

medical sttidents, was 38.81 (SD=5.78, SEM=2.75). The reliability (KR-21) is reported

to be .87.

Discussions with the author of the SKAT (H. Lief, personal communication,

December 13, 2001) highlighted six of the fifty items that are now considered

questionable or outdated. Therefore, based on the recommendations of the author of the

instrument, the six questionable items were omitted from the present study (see Appendix

G). Additionally, the current researcher noted eleven items that were considered poor

questions (see Appendix H) because these items are no longer relevant or serve as good

measures for current sexual knowledge. For example, "For every female that masttirbates

four males do." While previous literature has supported a higher prevalence of

masttirbation in males than females, these studies are typically targeted toward an

adolescent population. More recent research has shown that as women become more

comfortable with their bodies in later years, the prevalence of masturbation increases for

them. With that said, it is difficult to estimate the ratio of masturbatory males to

masturbatory females because of the taboo nature of the topic and because of other

limitations inherent in self-report items. Another example is, "Seven out often parents

desire fonnal sex education in the schools." While there is research that claims parental

43 support of sex education in the schools (Weerakoon & Stiemborg, 1996), it is unclear if this ratio represents an accurate portrayal of parents today. In total, 17 items were omitted from the original knowledge section of the SKAT, which resulted in a 34 item scale for the present study (see questions 15-48 in Appendix D).

Constinact validity for the SKAT has been demonstrated through studies that tested sex knowledge before and after an intervention designed to increase sexual knowledge. Lief (1988) reported that most participates showed a significant increase in scores on the knowledge subscale as a result of educational experiences designed to produce such changes (Bemard, 1977; Hadom & Grant, 1976; Lamberti & Chapel, 1977;

Schnarch & Jones, 1981).

In this study, a score for each subject was derived using the total number of correctly answered items for the 34 sex knowledge questions. This score was used in all statistical analyses requiring basic sex knowledge information. Each item on the basic sex knowledge scale will be worth one point. With 34 sex knowledge questions, it was possible for respondents to score between from 0 to 34. Higher scores represent more sex knowledge, while lower scores represent less sex knowledge.

Sexual Comfort scale

The Sexual Comfort scale was used to assess the comfort level of the therapist's when discussing sexuality-related topics. The measure was derived from a study intended to operationally define "sexuality comfort" (Graham & Smith, 1984). Graham and Smith (1984) conducted a qualitative study based on in-depth interviews with 32 sexuality educators who unanimously agreed that sexual knowledge does not ensure

44 comfort with that knowledge. Furthermore, the results of this sttidy lead the authors to create a list of 12 components that serve as evidence of sexuality comfort in sexuality

educators. Ten of the twelve components listed seem to be adaptable to serve as

indicators of sexual comfort for therapists. These 10 items from the Graham and Smith

(1984) study comprise the sexual comfort scale for the present study (see questions I lb,

13a-d,and 14a-j in Appendix D). The Sexual Comfort scale is constmcted with a Likert-

type response format ranging from 1 (strongly disagree) to 7 (strongly agree). Reverse

coding was implemented where appropriate. Higher scores indicate greater levels of

comfort with sexuality issues, while lower scores are an indicator of discomfort or

anxiety with sexuality issues.

Sexuality Discussions with clients

Currently there is no documented instmmentation available to measure therapist

sexuality-related discussions with clients. Thus, the Sexuality Discussion Scale was

developed as a 9-item self-report measure designed to assess the presence or absence of

sexual discussions with clients (see questions 10a-lOi in Appendix D). This measure was

constmcted using a Likert-type response format with scores ranging from 1 (strongly

disagree) to 7 (strongly agree) or 1 (never) to 7 (very often). Reverse coding was

implemented for question lOi. For this scale higher scores indicate increased willingness

of the therapist to initiate sexuality discussions with their clients.

45 Research Questions and Hypotheses

After a thorough review of the literature, it is clear that numerous questions remain unanswered conceming therapists' sexuality-related discussions with clients. The researcher addressed two of them in this study in an attempt to clarify how knowledgeable MFTs are about sex, and if they are discussing sexual issues with their clients. First; are therapists discussing sexuality-related issues with clients? Second; is their willingness to initiate sexuality-related discussions with clients influenced by their basic sexual knowledge, comfort with sexual matters, formal sexuality education, clinical

experience with sexual issues and experience addressing sexual issues with a supervisor?

The specific research questions, derivation of hypotheses, and the hypotheses themselves

are presented next.

Research Question I

Do therapists' sexual knowledge influence the likelihood that they will enter into

sexuality discussions with their clients?

Derivation of research hypothesis I

Clients expect that therapists will be knowledgeable about sexuality (McConnell,

1976; Nathan, 1986). Thus, therapists often find themselves in role of sex educator

(McConnell, 1976; Vesper & Brock, 1991). In these instances, therapists' sex knowledge

provides the foundation for problem resolution. If therapists do not have accurate sex

knowledge, they are unable to dispel or address clients' sexual myths or

misunderstandings or provide accurate information about sex and sexuality. Hypothesis I

46 was derived based findings on the importance of therapist sex knowledge when initiating sexual discussions with clients.

Hypothesis I. Marriage and family therapists with higher levels of sex knowledge will be more likely to initiate sexually related discussions with their clients than therapists with lower levels of sex knowledge.

Research Question II

Do therapists' comfort levels with sexuality-related material influence the

likelihood that they will enter into sexuality discussions with their clients?

Derivation of research hypothesis II

Therapist level of comfort has been described as an important variable in

influencing effective counseling (Graham & Smith, 1984). McCormell (1976) found that

subjects in her study exhibited a level of anxiety that would prove detrimental to their efforts to address sexual issues effectively. Several studies have emphasized the

importance for therapists to be at ease when discussing sexual matters with clients

(Belliveau & Richter, 1970; Bumap & Golden, 1967; Tmax & Mitchell, 1971). In fact,

Bumap and Golden (1967) have indicated that the physician's comfort with the subject of

sex was positively correlated with the frequency with which patients' sexual problems were addressed. Counselors in Kirkpatrick's (1980) study indicated that the ability to discuss clients' sexuality as easily as other concems was the most important area to focus on for counselor trainees. In a study based on sexuality educators (Graham & Smith,

1984), subjects suggested that teachers who have increased levels of comfort with

47 sexuality matters would be more willing to communicate about sexuality in general.

Unfortunately, no study until now has directly investigated the factors that potentially influence therapists' likelihood of initiating sexuality discussions with clients. Thus, the proposed relationship between therapist comfort level with sexually related issues and therapist sexuality discussions with clients served as the basis of Hypothesis II.

Hypothesis II. Marriage and family therapists with increased levels of comfort with sexually related matters will be more likely to initiate sexual discussions with their clients, than will therapists with lower levels of comfort with sexually related matters.

Research Question III

Do therapists' sexual knowledge influence their comfort level with sexual matters?

Derivation of research hypothesis III

Knowing facts about sexuality is not equivalent to being comfortable with what one knows (Graham & Smith, 1984). However, relevant literature indicates that sex knowledge increases comfort with sexual issues (Yallop & Fitzgerald, 1997). For example, occupational therapists in Yallop and Fitzgerald's (1997) study identified knowledge as the major reason for comfort with sexual issues and the factor that would increase their comfort with sexuality. Thus, Hypothesis III was formed based on these previous findings.

Hypothesis III. Marriage and family therapists' sex knowledge will have a direct, positive influence on their comfort with sexual issues.

48 Research Question IV

Do therapists' graduate sexuality education influence their overall sexual

knowledge?

Derivation of research hypothesis IV

The relationship between sexuality education and therapists' sex knowledge has

been discussed extensively in the literature (Alzate, 1982; Humphrey, 2000; McConnell,

1976; Nathan, 1986; Stayton, 1998; Weerakoon «fe Stiemborg, 1996). Health

professionals that have taken a formal sexuality education course have been found to be

more knowledgeable about the sexual response cycle, physiological changes across the

lifespan, sexual dysftinction and sexually transmitted diseases and infections. Hypothesis

IV derived from these findings.

Hypothesis IV. Marriage and family therapists' formal graduate level sexuality

education will directly and positively influence their sexual knowledge.

Research Question V

Does therapists' graduate level sexuality education influence their comfort level

with sexually related matters?

Derivation of research hypothesis V

Therapists' level of sexuality education has been identified as one of the

important characteristics related to comfort with sexuality-related issues (Anderson,

1986; Driscoll et al., 1982). Additionally, it has been shown that formal sexuality

education desensitizes therapists toward sexuality topics and increases the likelihood they

49 will recognize and address their personal values and feelings in this area (Stayton, 1998;

Weerakoon & Stiemborg, 1996). Several researchers (Anderson, 1986; Fyfe, 1980;

Stayton, 1998) agree that therapists need to become aware of their own sexuality before

helping others to explore sexual concems. Even though several studies have supported

the assumption that sexuality education for therapists would increase their comfort level

with sexuality issues, this assumption has not been investigated with marriage and family

therapists. Thus, Hypothesis V was derived to test the proposed relationship between

therapist sexuality education and therapist comfort with sexuality issues.

Hypothesis V. Marriage and family therapists with formal graduate level

sexuality education will be more comfortable with sexually related matters than therapists

without formal graduate level sexuality education.

Research Question VI

Do therapists' clinical experiences with sexual issues influence their sexual

knowledge?

Derivation of research hypothesis VI

Therapist clinical experience has been identified as an important influence on

therapist sex knowledge. For example, medical sttidents who actually conducted a sex

interview or even simply observed the process increased their sexual knowledge

compared to the medical students without the interview experience (Weerakoon &

Stiemborg, 1996). Thus, based on related data indicating a relationship between clinical

experience and sex knowledge. Hypothesis VI was formed.

50 Hypothesis VI. Marriage and family therapists' clinical experience with sexual issues will directly and positively influence therapist sex knowledge.

Research Question VII

Do therapists' clinical experiences with sexual issues influence their comfort with sexually related matters?

Derivation of research hypothesis VII

Stage two of Anderson's (1986) four stages of therapist comfort is "awareness of problems from a client point of view." Once therapists have explored the meanings and values of their own sexuality, they progress to stage two. In this stage therapists increase their level of comfort through clinical experiences that are related to sexual issues.

Research indicates that as therapists gain clinical experience with sexual issues they become more comfortable with sexuality-related issues in general (Yallop & Fitzgerald,

1997). Role-plays of sex-related counseling have also been shown to increase therapist comfort with sexuality issues (Fyfe, 1980). These findings are the basis for Hypothesis

VII.

Hypothesis VII. Marriage and family therapists with more clinical experience with sexual issues will be more comfortable with sexuality issues than therapists with less clinical experience with sexual issues.

51 Research Question VIII

Does therapist's experience addressing sexual issues in supervision influence their sexual knowledge?

Derivation of research hypothesis VIII

Given that sexual knowledge can be acquired through a variety of mediums, it

seems likely that addressing sexual issues in supervision could also be a contributing

factor. Nathan (1986) suggests that supervision is an additional avenue for therapists to

gain sex knowledge, beyond the classroom. Thus, Hypothesis VIII was derived out of

recognition of the relationship between supervision experience with sexual issues, and

therapist sexual knowledge.

Hypothesis VIII. Marriage and family therapists' supervision with sexual issues

will have a direct, positive influence on therapist sexual knowledge.

Research Question IX

Do therapists' experience addressing sexual issues in supervision influence their

comfort level with sexually related matters?

Derivation of research hypothesis IX

To date no research related to supervision experience with sexuality issues and

therapist comfort level with sexual issues has been conducted. However, it has been

established that participation of professionals with sexuality training is an important

component in the development of less experienced professionals (Weerakoon &

52 Stiemborg, 1996). Such training allows for modeling and role-playing, both of which have been linked to increased therapist comfort (Fyfe, 1980). Thus Hypothesis IX was based on the speculation that supervision experience influences therapist comfort levels.

Hypothesis IX. Marriage and family therapists' supervision experiences with sexual issues will have a direct, positive influence on therapist comfort with sexual issues.

Research Design and Analyses

Path analyses were done to frack the effects of the exogenous variables on the endogenous variables (see Figure 1). Initially a correlation matrix was mn for all variables in the path model and for the background variables. The variables we planned to investigate in this study included: therapist sexuality education, therapist clinical experience, therapist supervision with sexual issues, therapist sex knowledge, therapist sexual comfort, and therapist sexual discussion with clients. Additionally, the following background variables were examined: gender, age, values, education, area of discipline, years in practice, and average number of clients per week. To explore the variables as illustrated in Figure 1, several multiple regression analyses were conducted.

Only those variables that were significantly correlated with endogenous variables were included in the path analyses.

The first regression analysis was to examine the effects of therapist sexuality education and supervision experience addressing sexuality issues, therapist clinical

53 Sexuality Education

Therapist Basic Sexual Knowledge

Clinical Experience Sexuality Discussions

Sexual Comfort

Supervision witli Sexual Issues

Figure I. Initial Path Mode!

54 experience with sexuality issues, on basic sex knowledge. This analysis determined the amount of variance accounted for by the independent variables combined, as well as the strength of the relationship between each independent variable and the dependent variable.

The second multiple regression analysis planned to examine the influence of therapist sexuality education and supervision experience addressing sexuality issues,

therapist clinical experience with sexuality issues, and basic sex knowledge on therapist

comfort level with sexuality issues. The amount of variance explained by the

independent variables in therapist comfort level with sexuality issues was calculated.

Significant direct effects were noted.

The third multiple regression analysis was to examine the influence of therapist

sexuality education and supervision experience addressing sexuality issues, therapist

clinical experience with sexuality issues, therapist basic sex knowledge, and therapist

comfort with sexuality issues, on therapists' initiated sexuality discussions with clients.

Direct as well as indirect effects are noted in the analysis. Again, the percentage of

variance explained by the independent variables on therapist sexuality discussions with

clients are reported.

The results of each regression are presented. Next, the standardized Betas were

calculated into the path model, while removing any paths that were not found to be

significant. The final path model with the significant variables is presented in a figure. A

Decomposition table with indirect, direct, and total effects of each variable is presented in

a table.

55 Summary

In Chapter III, the procedures used in this research were described via a restatement of the problem, a discussion of the research design and analyses, and the hypotheses to be investigated. In addition, subjects were described, along with data collection protocol and a review of the measures to be used. Chapter IV presents the results of this study.

56 CHAPTER IV

RESULTS

Introduction

Resuhs of the research are presented in this chapter. Demographic characteristics of participants are summarized in tables and text, and the findings from each of the nine hypotheses tested in this study are enumerated. Hypotheses were tested using several multiple regressions (in the form of a path analyses). This chapter concludes with a svunmary of the results.

Demographic Characteristics of the Sample

A total of 175 AAMFT clinical members participated in this study. Of the 350 surveys that were mailed originally, four were retumed to the researcher with undeliverable addresses. Additionally, 18 members of this initial group solicited, requested not to participate and were not sent a survey. Therefore, a total of 328 surveys were mailed to the randomly selected sample. Of these, 138 participants completed and retumed the survey within 10 days of receiving the survey. The third mailing, (reminder postcard), yielded 37 additional retumed surveys. Two separate requests for replacement questionnaires were received as a result of the reminder postcard, however, neither of the requested replacement questionnaires were retumed to the researcher. Although the proposed study included a fourth mailing (replacement questionnaire) to the remainder of the sample that had not yet responded, the members of the committee decided to forgo the fourth mailing. This decision was based on several factors: (1) the sample size from

57 the first three mailings was large enough to conduct the proposed analyses; (2) with only two requests for replacement questionnaires prompted by the third mailing, it was doubtful that mailing a replacement questionnaire would significantly increase the sample

size; and (3) the anticipated response rate to a fourth mailing was deemed to not be cost effective. Therefore, with three of the four proposed mailings employed, a total of 175

surveys were completed and retumed to the researcher for the present study. In total, the response rate for this survey was 53%.

Tables 2 and 3 contain detailed descriptive statistical information about the

sample. Among the listed demographic statistics are personal values. Respondents in the

study rated their personal value system on a Likert-type response format ranging from 1

(traditional) to 7 (progressive). Higher scores indicate more liberal values, while lower

scores are an indicator of more conservative values. The mean for this sample was 4.8, which indicates a somewhat liberal value system for the overall group.

Of the 175 respondents in the study, 65 were male (mean age = 57 years; SD =

8.7) and 110 were female (mean age = 53 years; SD = 9.9). The females in the sample

indicated having less years of clinical experience than the males (16 years compared to

21 years). Both males and females in the study, reported seeing a similar number of clients each week (female mean = 20 clients; male mean = 21.5 clients).

T-tests were mn on gender, education level and certification as a sex therapist on therapists' sexuality discussions with clients. No significant difference was found for gender or education level with sexuality discussions. A significant difference was found for the 13 respondents certified as sex therapists: The certified sex therapists were more likely to initiate sexuality discussions with their clients (mean = 5.4; SD = .85), than

58 Table 2: Measures of Central Tendency and Variance for Demographic Variables

Characteristic Mean Standard Deviation

Age 54.1 9.6

Personal Values 4.8 1.4

Years in practice 17.9 8.9

Weekly clients 20.5 9.4

59 Table 3: Demographic Characteristics

Characteristic Frequency Percent

Gender

Female 110 62.9

Male 65 37.1

Education Level

Master's degree 131 74.9

Doctoral degree 40 22.9

PhD candidate 4 2.3

Area of Discipline

MFT 46 26.3

Social Work 20 11.4

Psychology 33 18.9

Counseling 23 13.1

Nursing 3 1.7

Education 11 6.3

Pastoral Counseling 6 3.4

Human Development 4 2.3

Behavioral Science 1 .6

Missing 28 16

60 Table 3: Continued.

Variable Frequency Percent

Second Master's 13 7.4

Sex Therapist certification

Yes 13 7.4

No 124 70.9

Missing 38 21.7

61 the respondents in the sample that were not certified sex therapists (mean = 4.6; SD =

1.3),t(137) =-2.15,p<. 05.

A one-way analysis of variance (ANOVA) was conducted to determine if respondents in a specified discipline differed with respect to initiating sexuality discussions with clients. Due to the low number of respondents in some of the categories, the original nine categories for the discipline variable were collapsed into the following six categories: MFT (n=46). Social Work (n=20). Psychology (n = 33),

Counseling (n = 23), Education (n = 11), Other (n = 14). No significant differences were found between the groups. An addhional ANOVA yielded no significant difference between respondents that have earned a second masters degree from those respondents with only one master's degree with respect to therapists initiating sexuality discussions with clients.

Preliminary Analyses

A preliminary analysis of the data indicated that the SKAT would not serve as an adequate scale of sexual knowledge for the present study. The SKAT yielded little to no variance within the sample, indicating that the present sample may be a well-informed group in terms of basic sexual knowledge. It may also mean that the SKATs format with tme-false questions does not adequately measure therapists' sexuality knowledge. The lack of variation on the SKAT is demonstrated by the sample mean of 28 on a 34-point scale and a standard deviation of 2.46.

As mentioned previously, the SKAT was not originally intended to measure the sexual knowledge of mental health professionals. Instead, the SKAT is aimed at

62 measuring the effectiveness of sexuality courses for undergraduate students and beginning medical students (Miller & Lief, 1979). By contrast, the sample for the present study consisted of adults who have all had exposure to various levels of higher education.

In other words, the majority of the respondents that comprised the current sample possess a good basic knowledge about sexuality issues, as measured by the SKAT. The low variance for the SKAT and poor reliability (alpha = .54) negatively influenced the

correlations between the SKAT scores and the other variables in the study (see Table 4).

Based on these findings, the SKAT was not used in the analyses for the path model.

In addition to the SKAT, the survey contained another sexual knowledge scale

that was created by the researcher. Initial analyses indicated that this additional scale,

developed to assess therapists' perceived sex knowledge, was a better fit for the model

and a better predictor of the dependent variable. The Perceived Sexual Knowledge scale

requires respondents to rate their level of knowledge on eight distinct sexuality

dimensions using a seven point Likert-type scale. The perceived sexual knowledge scale had better variance and reliability (alpha = .85) than the SKAT. This resulted in

significant correlations with other variables in the study (see Appendix C questions 12a-

12h). As a result of these findings, the Perceived Sexual Knowledge scale was put into the path model, in place of the SKAT. Hence, the model was adjusted to measure therapists' perceived sex knowledge instead of therapists' actual knowledge.

Another adjustment that was made, as a result of the initial findings, was the combining of the sexuality education variable with the supervision experience variable.

The high correlation between the sexuality education variable and the supervision experience variable was a source of concem. In retrospect, it became clear that most

63 Table 4: Pearson Correlations for Original Path Model Variables

Variable Education Clinical Supervision SKAT Comfort

Clinical .372*^

Supervision .574** .358**

SKAT .162* .103 .184*

Comfort 2^2** .173* .316** .118

Discussions .439** .188* .334** .198** 494**

*E<.05.

**E<.01.

64 supervision experiences for the sample occurred during their graduate education. In other words, the two variables were not measuring distinct phenomenon. Therefore, we combined the supervision and education scales to more accurately reflect the experiences of the clinicians. Additionally, an item from the clinical scale that addressed practicum experience was moved to the sex education and supervision scale, because practicum experiences are also inclusive of most graduate training programs. In this case, practicum experience refers to an extended amount of time (i.e., a semester) in which therapists' clinical experiences were devoted solely to the treatment of sexual issues.

Based on these changes, adjustments were made to the initial path model to incorporate

these modifications (see Figure 2). Rationale for these adjustments are detailed in

Chapter V.

In addition to an item being removed from the clinical experience variable, one of

the remaining items, "I regularly work with clients who present with sexual concems"

was weighted. The other items that comprise the clinical experience variable indicate

therapists' isolated or occasional clinical experiences with sexual issues. Compared to

the other items listed to assess clinical experiences with sexuality issues, this particular

item seemed qualitatively different from the others. Therefore, while the other items in

the scale received a "1" for a positive response, this item received a "2" for a positive

response.

The overall means, standard deviations, and ranges of the study's primary

variables are presented in Table 5. The overall correlations between the variables in the

final model are presented in Table 6.

65 Sex Education and Supervision

Perceived Sex Knowledge

Sexuality Discussions

Sexual Comfort

Clinical Experience

Figure 2. Adjusted Initial Path Model

66 Tests of Hypotheses

The first regression was conducted to examine the effects of two variables

(therapist sexuality education and supervision experience addressing sexuality issues and clinical experience with sexuality issues) on perceived sexual knowledge. Both of the exogenous variables had a significant direct effect on therapist perceived sexual knowledge. The independent variables explained 27% of the variance in therapists' perceived sexual knowledge (see Figure 3).

With the second multiple regression the researcher investigated the influences of three variables (therapist sexuality education and supervision experience addressing sexuality issues, clinical experience with sexuality issues, and perceived sexual knowledge) on comfort with sexuality matters. Although, clinical experience with sexuality issues did not have a direct effect on comfort with sexual content, sexuality education and supervision experience and perceived sex knowledge did. The exogenous variables explained 48% of the variance in therapist comfort with sexuality matters.

In the final regression the researcher examined the effects of four variables

(therapist sexuality education and supervision experience addressing sexuality issues, clinical experience with sexuality issues, therapist perceived sexual knowledge and therapist comfort with sexuality matters) on therapist sexuality discussions with clients.

Therapist perceived sexual knowledge did not have a significant direct effect on therapists initiating sexual discussions with clients. Therapist clinical experience with sexual issues was close in significance (p. = .08) and therefore worthy of notice. The independent variables explained 33% of the variance in therapists initiating sexuality

67 Table 5: Means, Standard Deviations, and Ranges of Variables in the Final Path Model

Characteristic Mean Standard Deviation Range

SupEd 4.2 2.0 10.0

Clinic 1.4 .61 3.0

Self Report 5.4 .83 3.4

Comfort 5.8 .78 4.4

Discussions 4.6 1.26 6.0

Note, n = 175 for all variables

Table 6: Pearson Correlations for Exogenous and Endogenous Variables

Variable SupEd Clinic Self Report Comfort

Clinic .552 **

Self Report .476** .443 **

Comfort .409** .315 ** .686**

Discussions .443** .382 ** .452 ** .494 **

*E < .05.

**p<.01.

68 Sex Education .20 and Supervision

Perceived Sex Knowledge

Sexuality .64 Discussions

.31

Sexual Comfort

Clinical Experience .14

Figures. Final Path Model

69 discussions with their clients. The final path model with the significant variables is

presented in Figure 3.

With the adjustment of the model to include therapists' perceived sexual

knowledge in lieu of their actual sexual knowledge, some of the hypotheses were

modified to reflect this change. In each instance where sexual knowledge was used in the

original hypotheses, it should be understood that perceived sexual knowledge is the

variable that was tested.

The findings did not fully support Hypothesis I: Marriage and family therapists

with higher levels of sex knowledge will be more likely to initiate sexually related

discussions with their clients than therapists with lower levels of sex knowledge.

Perceived sexual knowledge does not have a significant direct effect on sexual

discussions in the path model. There is, however, an indirect influence on sexual

discussions by perceived sex knowledge.

Hypothesis II was supported with a statistically significant direct effect between

therapist comfort with sexual issues and therapist sexuality discussions with clients. The

findings also supported the adjusted Hypothesis III: Marriage and family therapists' sex

knowledge will have a direct, positive influence on their comfort with sexual issues.

There was a strong direct effect between therapist perceived sexual knowledge and therapist comfort with sexual issues.

By adjusting the path model to combine sexuality education and supervision experience with sexuality issues into one variable, it also combines Hypotheses IV and

VIII: Do therapists' graduate sexuality education influence their overall sexual knowledge? and; Marriage and family therapists' supervision with sexual issues will have

70 a direct, positive influence on therapist sexual knowledge. Both hypotheses were supported with a statistically significant direct effect between sexuality education and supervision experience addressing sexuality issues and perceived sexual knowledge.

Likewise, the combination of sexuality education and supervision experience addressing sexuality issues into one variable also influenced Hypotheses V and IX:

Marriage and family therapists with formal graduate level sexuality education will be more comfortable with sexually related matters than therapists without formal graduate level sexuality education; and Marriage and family therapists' supervision experiences with sexual issues will have a direct, positive influence on therapist comfort with sexual issues. Both of these hypotheses were supported by the data. A significant direct effect was found between sexuality education and supervision experience variable and therapist comfort with sexuality matters.

The fifth hypothesis, was supported. It was hypothesized that MFTs clinical experience with sexual issues would directly and positively influence therapist sex knowledge. In the path model, there was a significant direct effect between clinical experience and therapist perceived sexual knowledge. In other words, therapists' clinical experience with sexual issues positively influenced their perception of their sexual knowledge.

Hypothesis VII was not supported by the data. Therapists' clinical experience with sexual issues did not directly effect their comfort with sexuality matters. However, therapists' clinical experience did have direct and indirect influences on therapists initiating sexuality discussions with their clients.

71 A decomposition table with indirect, direct and total effects of each variable is presented in Table 7. The decomposition table lists the variables that had an effect on the dependent variable, and illustrates the differences in the influences of these variables on therapists initiating sexuality discussion with their clients. Therapist comfort with sexual content the greatest direct influence on therapist initiated sexuality discussions, while sexuality education and supervision experience addressing sexuality issues had the second largest direct influence on therapist initiated sexual discussions with clients.

Therapist sexuality education and supervision experience and therapist comfort with sexual matters had the largest total impact on therapists initiating sexual discussions with clients, respectively. Therapists' perceived sexual knowledge had the third largest combined influence on sexual discussions, even though it did not have a direct influence.

Therefore, therapists' perceived sexual knowledge influences their likelihood of initiating sexuality related discussions with their clients, but only as it is mediated by a positive influence on comfort, which directly influences sexual discussions.

Summary

The results of this study were presented by dividing Chapter IV into three sections. First, demographic data related to the sample were presented followed by preliminary analyses, and tests of hypotheses. As expected, results indicated that therapists' certified in sex therapy were more likely to initiate sexuality related discussions with their clients, than therapists without a sex therapy certification.

72 Table 7: Decomposition Table

Variable Indirect Effects Direct Effects Total

SupEd .17 .20 .37

Clinical .05 .14 .19

Perceived .20 .20

Comfort .31 .31

73 Rationale was provided conceming the removal of the SKAT from the path model and the addition of the Perceived Sexual Knowledge scale in its place. Rationale was also

provided for the combination of the sexuality education variable with the supervision

experience variable. Initially these were two separate variables in the path model, they

were combined to form one variable (sex education and supervision experience) for the

final path model. Additionally, an explanation was provided with the hypotheses that any

of these adjustments influenced. Regarding the nine hypotheses posited at the outset of

this investigation, only two were not fully supported by the data. Contrary to the

hypotheses, no direct influence was found between therapists' perceived sexual

knowledge and therapist sexuality related discussion. Similarly no direct influence

between clinical experience and therapist comfort was found. The seven supported

hypotheses found direct influences on sexuality discussions by sexuality education and

supervision experiences, clinical experiences and comfort. Indirect influences on the

dependent variable were by sexuality education and supervision experiences, clinical

experience, and perceived sexual knowledge.

These results are interpreted and discussed in Chapter V as they relate to

therapists initiating sexuality discussions with their clients and other published research

in the area. Likewise, implications for therapy are presented, strengths and limitations of

the study and directions for future research are highlighted.

74 CHAPTER V

DISCUSSION

Introduction

Chapter V is organized into four major sections. First the study is summarized with a restatement of the problem and a description of the research hypotheses. Second, findings from the investigation are presented and placed in the context of related research. Third, methodological strengths and limitations are addressed. Finally,

Chapter V concludes with a discussion of suggestions for fiiture research and the implications of the findings for marriage and family therapists.

Summary of the Study

The purpose of this research was to examine direct and indirect influences on therapists initiating sexuality related discussions with their clients. Four variables were chosen for investigation: (1) therapist graduate level sexuality education and supervision experience addressing sexuality issues; (2) therapist clinical experience with sexuality issues; (3) therapist perceived sexual knowledge; (4) and therapist comfort with sexual content. These variables were hypothesized to directly and indirectly influence the dependent variable based on a review of the literature which suggested that sexuality education, supervision experience, clinical experience with sexual issues, sexual knowledge base and comfort with sexual content were important qualities for therapists to possess. However, research in this specific area of factors influencing therapists'

75 sexuality discussions with clients has been virtually nonexistent so very little empirical literature was available. Yet, numerous researchers have argued that sexual knowledge and comfort with sexual content is essential for competency in discussing, assessing and treating clients' sexual concems (Driscoll et al., 1982; Cross, 1991; Kirkpatrick, 1980;

McConnell, 1976; Stayton, 1998).

The constmct of Bowen's family systems theory was selected as a theoretical framework from which to understand the importance and implications of therapists initiating sexuality discussions with their clients. This framework also highlights the significance of therapists not initiating sexuality discussions. Through the family systems concept of differentiation, the influence of therapist comfort with sexual content was explored, and conversely, the influence of therapist anxiety. Bowen family systems theory encourages objectivity, which is only possible when the intellectual system is not overridden by the emotional or feeling system. In other words, one of the factors positively influencing differentiation is knowledge. Increased differentiation in therapists, or therapists' ability to distinguish between the feeling process and the thinking process, decreases their level of anxiety. As differentiation levels increase and anxiety decreases in therapists, Bowen family systems theory postulates that discussions around previously avoided (or potentially anxiety producing) topics can be initiated.

These concepts of Bowen family systems theory were believed to be applicable when investigating therapists' sexuality discussions with clients. Thus, this study sought to examine the influences of knowledge on therapists' comfort with sexual content and the influences of decreased anxiety, or comfort, on therapists initiating sexuality related discussions with their clients.

76 The sample for the study was comprised of 175 AAMFT clinical members from across the United States. All of the participants had higher education degrees and an average of 17 years of clinical experience. Each participant completed a 48-item close- ended questionnaire. Participants were instmcted to answer questions based on their personal and professional experiences, without the aid of supplemental materials. In addition to providing information about their demographics, graduate sexuality education, clinical experience with sexual issues, supervision experience addressing sexual issues, perceived sexual knowledge base, comfort with sexual content and sexuality related discussions with clients, participants also completed a 34-item sexual knowledge test taken from the Sexual Knowledge and Attitude Test (Lief & Reed, 1972).

After an initial correlation matrix was employed, it was determined that the sexuality education variable and the supervision experience with sexuality issues variable measured the same constmct. Based on these findings, these two variables were combined into one variable for the final model (SupEd). Additionally, the correlation matrix revealed a low correlation between the SKAT and all of the other variables in the model. The SKAT also had a low reliability score for this sample. Based on the interpretation of these findings, the SKAT was eliminated from the final model and determined to not be a sufficient measure of sexual knowledge for this sample. With previous research indicating that sexual knowledge was an influencing factor on sexual comfort and sexuality related discussions, a variable examining therapists' perceived sexual knowledge was added to the final model. Based on the correlation matrix and reliability scores, the therapists' perceived sexual knowledge variable was a better indicator of therapists initiating sexual discussions than was therapists' actual sexual

77 knowledge. Data were analyzed using several multiple regressions. A final path model with the significant variables was presented. A decomposition table with indirect, direct, and total effects of each variable was also presented.

Nine general hypotheses were tested. Hypotheses I and III predicted that therapist sexual knowledge would directly influence therapist initiated sexuality related discussions with clients and comfort with sexual matters respectively. Hypothesis II predicted that therapist comfort with sexual content would directly influence therapist initiated sexuality related discussions with clients. Hypotheses IV and V predicted that therapist formal graduate sexuality education would directly influence therapist sexual knowledge and comfort with sexual content respectively. Hypotheses VI and VII predicted that therapist clinical experiences with sexuality issues would have a direct effect on therapist sexual knowledge and comfort with sexuality matters, in that order.

Finally, Hypotheses VIII and IX predicted that therapist supervision experience with sexuality issues would have a direct impact on therapist sexual knowledge and comfort with sexuality related issues correspondingly.

Interpretation of Study Results

The findings suggest that sexuality education and supervision experience addressing sexuality issues is the best predictor of therapists' initiating sexuality related discussions with their clients. The sexuality education and supervision experience variable had both direct and indirect influences on the dependent variable. The direct effect for sexuality education and supervision was positively correlated with therapist initiated sexual discussions. As sexuality education and supervision experience

78 addressing sexuality issues increases, therapist initiated sexuality-related discussions with

clients increases. These findings support previous research (Driscoll et al., 1982; Graham

& Smith, 1984) that recognizes sexuality education as a potential tool for addressing the

many aspects of human sexuality. Both sexuality education and supervision could

provide mental health professionals with factual knowledge and experiential exercises

(ie. modeling) and dialogue that encourage sexuality discussions with clients.

The indirect effects of sexuality education and supervision experience addressing

sexuality issues are explained in a similar fashion. SexuaUty education and supervision

experience have an indirect effect on the dependent variable through both, perceived

sexual knowledge and comfort with sexual matters. Therefore, as the sexuality education

and supervision experience of a therapist increases the data seem to suggest that they are

more likely to perceive themselves as knowledgeable about sex and their level of comfort

with sexual matters increases. Again, it is through sexuality education and supervision

experiences that most therapists are exposed to factual sex knowledge and provided with

opportunities to explore and challenge their anxieties around sexuality. These findings

support the work of Driscoll, Coble, and Caplan (1982) who studied the sex knowledge

of family physicians and found that formal sexuality education was considered an

important contributor to increase sex knowledge, comfort levels with sexual content and

willingness to address sexual issues. It seems that for this sample, the same holds tme for

supervision experiences addressing sexuality issues.

The finding that therapist comfort with sexual content was the second strongest

influence of therapists initiating sexuality related discussions with their clients coincides

with the results of previous research on the developmental stages of therapists as they

79 gain comfort with sexuality matters (Anderson, 1986; Nathan, 1986). While both

Anderson and Nathan discuss the influence of increased sexual knowledge on comfort with sexual content, they also recognize increased sexuality related discussions with clients as a developmental benchmark indicating increased comfort with sexual content.

Based on previous literature and the present findings, as therapists gain comfort with sexuality related matters they are more likely to initiate therapeutic discussions focusing on sexuality related issues. This finding also supports the Bowen family systems concept that as anxiety decreases more flexibility in dialogue is possible.

A similar explanation supports the indirect effect that perceived sexual knowledge has on sexuality discussions, as mediated by therapists' comfort with sexual matters.

Previous research has consistently linked sexual knowledge to increased comfort with sexual content (Anderson, 1986; Nathan, 1986). The results of the present study support a strong direct influence of perceived sex knowledge on therapists' comfort. Therefore, for these therapists the data suggests that as they increase their perception of their sexual knowledge they feel more competent and self-confident in the area. The positive influences of increasing their sexual knowledge expands their comfort level with sexual issues, which in tum, creates space in sessions for addressing sexual issues with their clients.

Although clinical experience had both direct and indirect effects on sexuality related discussions with clients, it also had the lowest total effects on the dependent variable. In other words, while clinical experiences of the sample influenced their likelihood to initiate sexuality discussions with their clients, it had the least predictive value of all of the variables in the model. The positive direct effect between clinical

80 experience and sexuality discussions indicates that as therapists' clinical experience with sexuality issues increases, the likelihood of them initiating sexuality discussions with clients also increases. These findings suggest that as therapists gain clinical experiences with sexual issues, they may be more willing to initiate similar types of discussions in the

future.

Clinical experiences with sexual issues was found to have an indirect influence on

sexual discussions through perceived sexual knowledge. Therefore, as therapists gain

clinical experience with sexual issues, the perception of their sexual knowledge increases.

Surprisingly, clinical experience with sexual issues does not directly influence therapists'

comfort with sexual content. For this sample, as therapists work more regularly with

clients on sexuality issues, it does not directly influence their comfort with sexual

content. This finding may be explained in that participants were asked about their level

of clinical experience with sexual issues, but were not asked about the process or

outcome of those sessions. It cannot be assumed that all clinical experiences with

sexuality issues are growing or teaming experiences for the therapist. Thus, it could be

that not all clinical experiences accounted for by this sample were positive experiences.

If some therapists initiated sexuality discussions reluctantly or begmdgingly, it may not

have been a situation that increased their comfort with sexual content.

While this finding was contrary to Hypothesis VII, it makes an important

contribution that was unexpected. The fact that clinical experience with sexuality issues

does not directly effect comfort with sexuality content, provides further support for the

importance of a strong sexuality education and supervision background. It is through

increased sexuality education and supervision experiences that therapists increase their

81 comfort with sexual content, which is the highest predictor of them initiating sexuality discussions with clients. According to the current study, sexuality education and supervision experiences seem to be the comerstone for therapists' base level of comfort.

It is through sexuality education and supervision that sex knowledge is acquired and comfort levels are increased. On the other hand, clinical experiences with sexuality issues may simply reinforce therapists' base status of comfort. If therapists have a low base level of comfort (discomfort) with sexuality issues, their comfort level does not increase as a result of more clinical experience with clients. Consequentially, therapists with high comfort levels with sexuality issues do not increase their comfort levels solely through clinical interactions with clients. It is through sexuality education and supervision that comfort levels are increased. Therefore, for this study regardless of the amount of clinical experiences with sexuality issues, it is unlikely that therapists' comfort levels will increase without some exposure to sexuality education and supervision.

The results of this study indicate that therapists' perceived sexual knowledge base had more of an influence on sexuality related discussions than did therapists' actual sex knowledge. In other words, the perception of possessing higher levels of sexual knowledge increased the likelihood of therapists initiating sexuality related discussions with their clients more so than the level of sex knowledge that therapists actually possessed. Additionally, as therapists' perceived themselves to be more knowledgeable about sexuality matters, their comfort with sexual content increases, which in tum increases the likelihood that they will initiate sexual discussions.

It is of interest to note that neither basic knowledge (SKAT) nor perceived sexual knowledge had a direct influence on sexuality discussions with clients. This finding may

82 contradict the Bowen family systems concept of achieving greater degrees of differentiation. In the framework of differentiation, as therapists increase their sexual knowledge, their intellectual advancement in the area should increase their willingness to initiate sexual discussions with clients. Without the mediating variable of comfort, it seems that objectivity and intellectual reasoning do not necessarily create more flexibility in dialogue. These findings indicate that a perception of possessing sexual knowledge is not enough for therapists to imtiate sexual discussions with their clients. Cross (1991) reiterated these findings by suggesting that professionals with basic sex knowledge may be unable to be of help to a client because of his or her own discomfort (or anxieties) about sexuality. Bowen consistently highlighted the importance of therapists to be a non- anxious presence during anxious times in session. When therapists' anxiety is increased in session, sexuality discussions, and other uncomfortable topics, may be avoided.

None of the demographic variables influenced therapists' sexuality discussions with clients. These findings indicate no difference between male and female therapists in regard to engaging clients in therapeutic discussions on sexuality related matters. No differences regarding the dependent variable were found between therapists with various levels of higher education or between the various areas of discipline represented in the sample. Additionally no differences were found based on the years in practice or the number of clients seen weekly. These findings are important because they further underscore the important impact of sexuality education and supervision for therapists.

Sexuality education and supervision increase therapists' comfort with sexual content and discussions with clients about sexuality issues, regardless of age, gender, the discipline for which the therapists identifies or years in practice.

83 There was a positive correlation between therapists certified as sex therapists and the likelihood of initiating sexual discussions. This finding is supported by the significance found in the present study's model. All of the variables included in the final path model are components of the sex therapy certification process. Therefore, therapists certified in sex therapy receive sexuality education and supervision, clinical experience addressing sexuality issues, sex knowledge, and exercises and experiences to increase comfort with sexual content. Additionally, it can be presumed that therapists obtaining a certification in sex therapy are inherently more open to the idea of discussing sexuality issues in session.

Methodological Strengths and Limitations

In consideration of the strengths associated with this investigation, much of the literature on therapists initiating sexuality discussions with clients is descriptive in nature, with no studies empirically testing factors that influence these types of discussions. A strength of this study is its attempt to empirically test some of the variables that had been hypothesized in previous literature as influences on this phenomenon. Additionally, the majority of the studies addressing sexuality discussions with clients use samples of therapists-in-training, physicians, sexuality educators or other various mental health professionals. The use of AAMFT clinical members in this study contributes to the current body of marriage and family therapy literature.

Another strength of this study is the inclusion of therapists' perceived sex knowledge as a predictor for therapists' comfort with sexual content and therapists sexuality related discussions with clients. This variable had a higher reliability score than

84 the SKAT, and served as a better measure of sexual knowledge than the SKAT for this sample. No research to date has examined therapist sex knowledge from this perspective.

These findings present a new facet from which to study and understand human sexuality.

An overall limitation to the study is the self-report nature of the survey. By mailing participants a survey for them to complete at home, there may have been confusing or vague questions that were unable to be clarified. With self-report there is also the possibility of intentional false reporting. For various reasons, participants could have inflated the occurrence of sexual discussions with clients, or other variables measured in the study. Furthermore, while participants were instmcted not to use any

supplemental aids in answering the sex knowledge section of the survey, there was no way to ensure that these materials were not used. The SKAT was not used in the final

analyses so this limitation does not directly influence the findings of this study.

However, the potential use of supplemental materials could be the reason for high scores

and low variance on the SKAT for this sample.

The second methodological weakness in this research concems the SKAT.

Although reliability for this instmment has been reported as satisfactory in previous

studies and it is the most widely used sex knowledge instrument, the reliability was found

to be quite low in this investigation. Addhionatty, Alzate (1991) wamed that the

"knowledge section of the SKAT, which is composed of tme-false items, has about a

50% probability of being guessed correctiy by individuals ignorant of the right answer"

(p. 267). Furthermore, there was tittle to no variance on the SKAT with this sample. It

could be that this instmment was designed to measure basic sex knowledge and the

sample for this study was more highly educated than past samples. Overall, the sample in

85 this study may have been a welt-informed group in regard to basic sex knowledge.

Furthermore, the instmment is now dated given that it has not been revised since the

1970s. Therefore, there is no reflection of the impact that AIDS or the Intemet has had on various aspects of sexuality. There has also been no attempt to update questions or answers that may imply different meanings now. Thus, that no relationship between basic sex knowledge and sexual discussions was found should not be unexpected given the limitations described. The researcher recommends that a more reliable measure of mental health professionals' sex knowledge be created before a relationship between these two variables is mled out. It is clear from these findings that more measures are needed to objectively assess the sexual knowledge of mental health professionals.

The third limitation has to do with measurement. It specifically concems the questions used to assess supervision experience. It became clear retrospectively that most of the supervision experiences occurred during graduate education. Therefore, the researcher adjusted the final model. It would have been a more meaningful question if a distinction had been made between supervision experiences that occurred during graduate education and post-graduate supervision and consultation experiences. Making this distinction would help to separate graduate education experiences from other influential experiences.

This distinction is important because the execution of supervision in these two domains are potentially different. Magnuson, Norem, and Wilcoxon (2000) emphasized in their article that while guidelines and strategies for clinical supervision of graduate students is prevalent, the same cannot be said for clinical supervision of post-graduate students. While graduate school supervisors often work as a team, supervisors of post-

86 graduate counselors often assume sole responsibility for their supervisee's clinical work without knowledge of previous assessments of his or her clinical work and without the

aid of a course syllabi to serve as a guide for evaluation. Furthermore, supervisors in

graduate school programs typically have opportunites to provide live supervision, while

supervisors of post-graduate students often have limited contact with the supervisee and

less opportunities to provide direct supervision (Magnuson et al., 2000).

Similarly, making a distinction between graduate and post-graduate supervision

experiences would help to make a distinction between supervision experiences and

sexuality education. For this study, the final model combined the sexuality education

variable with the supervision variable. While combining these two variables was

necessary for the present study, it is difficult to determine the influences that each of

these separate experiences has on therapists initiating sexuality discussions. Creating

questions that address these two experiences separately would provide a better

understanding of the influences that each experience has on therapists' sexuality

discussions with clients. For the present study, the influence of sexuality education and

supervision can only be discussed collectively.

A final limitation of the study is the sample. Originally a random sample of 350

therapists was selected for this study. Of those 350 individuals, 175 therapists completed

and retumed surveys. While the response rate for the study is considered adequate, it

would be interesting to study the differences between therapists that respond to sexuality

surveys and those that do not. The original sample of 350 therapists could become a

sample of two subgroups: (1) therapists that complete sexuality surveys and (2) therapists

that do not participate in sexuality research. Since it has been documented that sexuality

87 issues are commonly avoided by professionals (Driscoll et al., 1982; Moore, 1985;

Stayton, 1998), it may be that the results to this study are only generalizeable to the types of therapists that would participate in sexuality focused research. It may be that the participants in this study are more likely to initiate sexuality discussions with clients and with researchers, than the therapists that chose not to participate in the study.

Directions for Future Research

This study investigated the influences of four variables (therapist sexuality education and supervision experience, clinical experience with sexuality issues, perceived sex knowledge, and comfort with sexual content) on therapists initiating sexuality discussions with their clients. The findings of this study indicate a significant relationship between sexuality education and supervision experience on all three of the endogenous variables (perceived sex knowledge, comfort with sexual content and sexuality discussions with clients). Research in this area would benefit by exploring these relationships further. Specifically, it would be helpful to understand the implications of various approaches to sexuality education and supervision on the variables in question.

It would be of particular interest to further investigate the sexuality education curriculum of accredited marriage and family therapy programs. A few questions are raised in regard to this area: (1) How is sexuality education taught at each program?; (2)

What are the outcome differences between programs that incorporate an entire course devoted to sexuality education and programs that address sexuality education throughout other courses in the curriculum? (3) Which sexuality education methods are the most

88 effective for influencing therapists' perceived sexual knowledge, therapists' comfort with

sexual content, and therapists' initiating sexuality issues with their clients?; (4) How are

supervisors addressing sexuality issues with therapists?; (5) What supervision

methodologies are the most effective for influencing therapists' perceived sexual

knowledge, therapists' comfort with sexual content, and therapists initiating sexuality

discussions with their clients?; (6) What is unique about the sexuality education and

supervision experience that has such a strong positive influence on therapists initiating

sexuality discussions with clients?

Presently there have been no studies conducted investigating the influence of

supervision on therapists initiating sexuaUty related discussions. With supervision being

the second highest predictor of sexuality discussions in this study, it seems imperative for

more research to be conducted in this area. In general, it seems that sexuality research in

the marriage and family therapy field would benefit from a better overall understanding

of the impact of supervision on therapists development in this area.

It is evident from the discussion section that the mental health field in general is

lacking an adequate instmment to assess sex knowledge. A more reliable and valid

instmment is needed before the constmct of therapist sex knowledge can be further

examined. In particular, an instrument with updated trends and accurate information that

is more reflective of sex knowledge as it pertains to mental health professionals and their

clients. An instmment in a format other than true-false, would probably yield more

accurate results as well.

The introduction of therapists' perceived sex knowledge to this study has important implications for future research. Measuring therapists' sex knowledge as they

89 perceive it to be, proved to be an influential factor on comfort with sexual content and initiating sexuality discussions. These findings signify the importance of therapists feeling competent, regardless of their actual competency level. Therapists would benefit

by understanding factors that influence their perceptions about their sex knowledge, and

strategies for increasing their feelings of competency. With a more accurate measure of

therapists' basic sex knowledge, it may also be of interest to study the relationship

between perceived sex knowledge and actual sex knowledge.

Overall, research in this area could be refined and improved with a format that

would provide more detailed and contextual information than the current survey utilized.

A more open-ended survey or face-to-face interview might clear-up any confiising or

misleading questions, while gathering more data simultaneously. A more open-ended

approach may have clarified some unclear items such as: post-graduate supervision and

clinical experience versus in school experiences, as well as assessing the personal

experiences and influences of those sessions. A face-to-face interview methodology

may begin to answer some of the questions raised about the differences fovmd between

therapists that participate in sex research and those that choose not to. Sexuality research

would benefit significantly by finding avenues for accessing the unheard voices in this

field.

Bowen family systems theory appears to serve as an appropriate theoretical model

for conceptualizing and understanding the complexities of influences on therapists'

discussions in session. For future research, it may be informative to investigate other

potentially anxiety producing topics, with Bowen family systems theory as the theoretical

model. That is, in order to fully understand the influences of therapists initiating

90 sexuality discussions, we also need to assess how they are successful at initiating other anxiety producing topics in session. It may also be of interest to investigate the relationship between therapists undertaking a sexuality education course (or supervision experience addressing sexuality issues) and the process of differentiation of self

Finally, this study encourages researchers to continue building on the methods of

studying sexuality discussions by addressing the limitations and suggestions described in the present study. The variables in the present study do not account for all of the variance

in therapists initiating sexuality discussions with clients. Therefore, other potentially

influencing factors should be investigated. Greater understanding of therapists' sexuality

discussions with clients across ethnic, religious, and sexual orientation would be

beneficial to researchers and professionals alike.

Clinical Implications for Marriage and Family Therapists

A review of the literature reveals that studying sexuality discussions with clients has primarily focused on physicians, occupational therapists and sexuality educators.

Presently, mental health professionals are finding it necessary and desirable to address various aspects of clients' sexuality. The results of this study indicate that having a high level of comfort with sexual content is a precursor for therapists initiating sexuality related discussions with their clients. For clinicians, increasing personal comfort levels with sexual content seems to be more important than perceiving themselves as knowledgeable in the area. Therefore, incorporating venues that facilitate comfort with sexual content seems cmcial for graduate and therapist training programs. Based on the findings of this study, comfort with sexual content seems to be increased by therapists'

91 perceiving themselves as knowledgeable about sex and by therapists receiving sexuality education and supervision experiences addressing sexuality issues.

Sexuality education and supervision experience with sexual issues were indicated as fundamental components for therapists to build comfort with sexual content in this study. It is through sex education and supervision that therapists may be given opportunities to become aware of the diverse aspects of sexuality, and their personal anxiety around those issues. Depending on the methodologies employed in sexuality education and supervision, the commonality of these variables may be an interactive or experiential component. In other words, by initiating dialogue about sexuality issues or role playing sexual discussions, sexuality education and supervision increase therapists' comfort with sexual content.

One of the sexuality education models that incorporate a more experiential approach is the comprehensive model (see National guidelines task force, 1996;

Weerakoon & Stiemborg, 1996). This approach to sex education encourages therapists to process information beyond the cognitive level. While knowledge is an important component to this model, affective and behavioral leaming are equally emphasized with this approach. This model guides therapists through self-awareness and leaming processes that encourage them to reexamine and challenge their anxieties around sexuality.

The comprehensive model for sexuality education may be similar to the experiences shared by therapists that have had positive experiences addressing sexuality issues with supervisors. Ideally, supervisors would initiate conversations about sexuality issues present in session. These conversations become an experiential leaming

92 experience for therapists, which will potentially become isomorphic of the interactions between therapists and clients. Creating awareness of clients' sexual issues, addressing therapists' anxieties around sexual issues, and encouraging therapeutic dialogue around these issues has the potential to be addressed successfully through sexuality education and supervision alike.

Knowing the important role that sexuality education plays for therapists gaining comfort with sexual content and initiating therapeutic discussions with clients about sex, it seems important for COAMFTE to incorporate a stronger emphasis on sexuality education in the accreditation standards. Presently, the amount of time that accredited programs devote to sexuality education in their curricula is unclear, other than the requirement that students must devote some time to addressing sexuality issues.

Therefore, while some programs may devote an entire three credit course to addressing sexuality issues, it is possible that some programs only address sexuality issues during a single class meeting. Likewise, the content and approaches to sexuality education in these programs are not regulated by the accreditation standards. With sexuality education and supervision serving as a comerstone for therapist comfort with sexual content, it seems that regulating the amount of time programs devote to sexuality issues is important. More than time, it seems cmcial that marriage and family therapy programs implement a sexuality education approach that encourages therapists to become aware of the various facets of human sexuality.

The other comerstone for therapists initiating sexuality discussions with their clients is supervision experience addressing sexual issues. No research to date has been conducted on the influence of supervision experience with sexuality issues on therapists'

93 comfort level with sexual issues. However, it has been established that participation of professionals in sexuality training is an important component in the development of less

experienced professionals (Weerakoon & Stiemborg, 1996). Such training allows for

modeling and role-playing, both of which have been linked to increased therapist comfort

(Fyfe, 1980). Likewise, supervision may serve as a venue for modeling sexuality

discussions as well as provide opportunities for role-playing those types of conversations.

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Yallop, S. & Fitzgerald, M. H. (1997). Exploration of occupational therapists' comfort with client sexuality issues. Australian Occupational Therapy Joumal, 44, 53-60.

99 APPENDIX A

THE TEXAS TECH UNIVERSITY COMMITTEE FOR THE

PROTECTION OF HUMAN SUBJECTS APPROVAL LETTER

100 TEXAS TECH UNIVERSITY

Office of Research Services

Box 41035, 203 Holden HaU Lubbock, TX 79409-1035 (806) 742-3884 FAX (806) 742-3892

May 20,2002

Dr. Steven M. Harris Kelli W. Hays Human Dvpt & Family Studies MS 1162

RE: Project 02111 The influence of sexuality education, clinical experience, supervision, sex knowledge and comfort with sexuality issues on therapists' addressing sexuality issues with clients

Dear Dr. Harris:

The Texas Tech University Committee for the Protection of Human Subjects has approved your proposal referenced above. The approval is effective from May 1,2002 through April 30, 2003. You will be reminded of the pending expiration one month prior to April 30,2003 so that you may request an extension if you wish.

The best of luck on your project. Sincerely,

Dr. Richard P. McGlynn, Chair Human Subjects Use Committee

An EEO / Affirmative Action Institution

101 APPENDIX B

PRENOTICE LETTER

102 Date

Name Address City, State Zip

Dear MFT Professional

A few days from now you will receive in the mail a brief survey for an important research project that I am conducting through Texas Tech University. The survey that I am requesting you to complete, addresses some of your therapeutic training, practices and experiences in the area of human sexuality. The data collected from this survey contributes significantly to the completion of my doctoral dissertation. As a clinical member of AAMFT, you have been randomly selected to participate in my study.

I am contacting you as a courtesy, to give you advance notice so that you can plan for 15 minutes next week to complete my survey. If you would prefer not to participate in this important study, please contact me within 3 days of receiving this letter (contact information is listed below). Otherwise, a survey will be mailed to you during the following week.

Thank you for your time and consideration. It's only with the generous help of clinicians like you that my research can be successfiil.

Sincerely,

Kelli W. Hays, Ph.D. candidate Steven M. Harris, Ph.D., Advisor Marriage and Family Therapy Program Human Development and Family Studies Texas Tech University Texas Tech University Lubbock, TX 79409-1162 Lubbock, TX 79409-1162

Email: [email protected] Phone: (817)657-4236

103 APPENDIX C

COVER LETTER

104 My name is Kelli Hays and I am a doctoral student in the Marriage and Family Therapy program at Texas Tech University. You should have received a letter in the past week requesting your participation in my study.

I am interested in knowing more about how and under what circumstances therapists discuss sexuality issues with their clients. Answering the enclosed brief survey will help identify factors that influence sexuality discussions in therapy. The survey will also address your current knowledge about sexual issues and comfort level with these issues.

This research will help family therapists understand the many factors that influence a therapist's willingness to discuss sexuality issues with clients. The questions in the survey are in reference to you and your clinical experiences. Completing and retuming the survey serves as consent for participation in the study. Be assured that your confidentiality will be protected. A questionnaire identification number is printed on the back cover of the questionnaire to ensure that your name will be deleted from the mailing list when it is retumed. Your data will only be considered in aggregate form. In no way will you your identity be revealed as a participant in this study.

I appreciate your consideration to participate in my study. Participation in this study is voluntary. However, you can help me significantly by taking a few minutes to share your experiences and training regarding human sexuality issues. Please complete the survey and retum it within the next 10 days. Please retum the survey in the self-addressed and stamped envelope provided. A reminder postcard will be mailed if your completed survey is not retumed during this time.

Sincerely,

Kelli W. Hays, Ph.D. candidate Steven M. Harris. Ph.D., Advisor Texas Tech University Human Development and Family Studies Lubbock, Texas 79409-1162 Texas Tech University Lubbock, Texas 79409-1162

Email: [email protected] Phone: (817)657-4236

105 APPENDIX D

QUESTIONNAIRE

106 General Instmctions Please circle the following responses or fill in the blank with the appropriate information about you. Please answer each question without the aid of supplemental materials. The completion and retum of this survey serves as consent to participation in the study.

Directions: Please circle the following responses or fill in the blank with the appropriate information about you. 1. Gender 2. Age

3. I consider my values to be: Traditional Progressive (conservative) (liberal) 12 3 4 5 6 7

4. Your highest level of education and discipline completed (i.e. Masters Social Work or Doctorate MFT): A. Master's B. Doctorate C. I have received certification as a sex therapist?

5. How many years have you been in practice?

6. During those years how many clients have you seen on average, per week?

7. Graduate sexuality training, (circle all that apply) A. I had no graduate courses in human sexuality. B. I had some training in human sexuality, as a component in a graduate level course. C. I had one entire graduate course in human sexuality. D. Sexuality training was integrated throughout my curriculum. E. I have attended workshop(s) on sexuality. F. I actively read in the area of sexuality, stay current with sexuality issues. G. I have taught a graduate course on sexuality.

107 8. Clinical experience with sexuality issues, (circle all that apply) A. I have no clinical experience with sexuality issues. B. I have clinical experience with only one or two cases involving sexuality issues. C. I occasionally work with clients on sexuality issues. D. I participated in a practicum experience devoted solely to the treatment of sexual issues. E. I regularly work with clients who present with sexual concems.

9. Supervision experience with sexuality issues, (circle all that apply) A. I have had no discussions with a supervisor about sexuality issues. B. 1 have discussed sexuality issues in supervision on one or two isolated occasions. C. I have occasionally discussed sexuality issues with a supervisor. D. I have discussed sexuality issues with a supervisor during my graduate training. E. I have regularly discussed sexuality issues in supervision. F. I have consulted with colleagues about clients' sexual concems.

10. Every therapist has a system for assessing and initiating discussions about specific client problems. Please answer how much the following statements reflect your practice habits regarding the assessment and initiation of discussions on sexuality-related issues.

1 assess for and initiate therapeutic conversations on: Never Sometimes Very Often Sexually transmitted diseases/infections 2 3 4 6 7

Sexual dysfunction 2 3 4 6 7

Client satisfaction with their sexual life 2 3 4 6 7

Client's typical sexual interaction pattem 2 3 4 6 7

Reproduction and/or contraception 2 3 4 6 7

Sexual orientation 2 3 4 6 7

Sexual relationship enhancement 2 3 4 6 7

Sex abuse 2 3 4 6 7

108 Strongly Strongly Disagree Agree I only assess and initiate conversations on sexuality related issues when the client states that it is a concem. 1 2 3 4 5 6 7

11. Please indicate your reaction to each of the following statements, using the following scale: Strongly Strongly Disagree Agree My training at the graduate level in human sexuality was adequate.

I feel comfortable working with clients' sexual issues or concems.

I believe that I am knowledgeable about human sexuality. 2 3 4 5 6 7

I prefer not to work with clients who present with sexual issues. 2 3 4 5 6 7

My clinical supervisors addressed sexuality issues when necessary. 2 3 4 5 6 7

In my family of origin, sex was discussed openly. 2 3 4 5 6 7

Considering all of my experiences with sexuality, I find myself hesitant to approach this topic with clients. 2 3 4 5 6 7

109 12. Using the following scale, indicate your knowledge base about the following:

No Some Very Knowledge Knowledge Knowledgeable

Sexually Transmitted Diseases 3 4 5 6 7

Sexual dysfunction 2 3 4 5 6 7

Reproduction and contraception 2 3 4 5 6 7

Sexual Orientation 2 3 4 5 6 7

Sexual relationship enhancement 2 3 4 5 6 7

Sex abuse 3 4 5 6 7

Sexual development across the lifespan

Effects of prescription and illegal dmgs on sexual functioning

13. Please indicate how comfortable you are or would be discussing sexuality issues with the following groups: Very Somewhat Very Uncomfortable Comfortable Comfortable

Clients 1 2 3 4 5 6 7

Students/Trainees 1 2 3 4 5 6 7

Supervisors 1 2 3 4 5 6 7

Colleagues 1 2 3 4 5 6 7

110 14. Please indicate your reactions to the following statements using the following scale: Strongly Strongly Disagree Agree I respond openly and confidently when my sexual values are challenged. 1 2 4 5 6 7

I communicate effectively about sexuality. 1 2 4 5 6 7 I use sexual vocabulary which is appropriate to the situation. i

I am sensitive to and respectful of others' feelings and anxieties towards sexual matters. 1

I encourage clients to explore their own sexual issues. 1

I encourage clients to explore their own sexual values. 1

I am not concemed about how I influence clients' sexuality. 1

I am confident in my knowledge about sexuality. 1

I appear poised in session when addressing sexual matters. 1

I find myself lacking respect for and feeling intolerant of others sexual values and practices. 1

Please answer the following questions based on your current knowledge. Please do NOT use any supplemental materials to aid in answering the questions. Each of the following statements should be answered either T = tme or F = false.

15. Pregnancy can occur during natural menopause (gradual cessation of menstmation).

16. Most religious and moral systems throughout the world condemn premarital intercourse.

17. A woman does not have the physiological capacity to have as intense an orgasm as a man. Ill _18. There is no difference between men and women with regard to the age of maximal sex drive.

_19. The use of the condom is the most reliable of the various contraceptive methods.

_20. Transvestitism (a form of cross-dressing) is usually linked to homosexual behavior.

_21. Homosexuals are more likely to be sexually exceptionally creative than heterosexuals.

_22. A woman who has had a hysterectomy (removal of the utems) can experience orgasm during sexual intercourse.

_23. Those convicted of serious sex crimes ordinarily are those who began with minor sex offenses.

_24. One of the immediate results of castration in the adult male is impotence.

25. The body build of most homosexuals lacks any distinguishing features.

26. Masturbation by a married person is a sign of poor marital sex adjustment.

27. Exhibitionists are latent homosexuals.

28. A woman's chances of conceiving are greatiy enhanced if she has an orgasm.

29. Only a small minority of all married couples ever experience mouth-genital sex play.

30. Impotence is the most frequent cause of sterility.

31. Certain foods render the individual much more susceptible to sexual stimulation.

32. A high percentage of those who commit sexual offenses against children are made up of the children's friends and relatives.

33. In our culture some homosexual behavior is a normal part of growing up.

34. Direct contact between penis and clitoris is needed to produce female orgasm during intercourse.

35. For a period of time following orgasm, women are not able to respond to fiirther sexual stimulation.

112 36. Impotence in men over 70 is neariy universal.

_37. Certain conditions of mental and emotional instability are demonstrably caused by masturbation.

38. Direct stimulation of the clitoris is essential to achieving orgasm in the woman.

_39. Varied coital techniques are used most often by people in lower socioeconomic classes.

40. Individuals who commit rape have an unusually strong sex drive.

41. The rhythm method (refraining from intercourse during the six to eight days midway between menstmal periods), when used properly is just as effective as the pill in preventing conception.

42. Menopause in women is accompanied by a sharp and lasting reduction in sexual drive and interest.

43. People in lower socioeconomic classes have sexual intercourse more frequently than those of higher classes.

44. For some women, the arrival of menopause signals the begirming of a more active and satisfying sex life.

45. Lower-class couples are generally not interested in limiting the number of children they have.

46. Excessive sex play in childhood and adolescence interferes with later marital adjustment.

47. There is a trend toward more aggressive behavior by women throughout the world in courtship, sexual relations and coitus itself

48. Douching is an effective form of contraception.

Thank you for your participation in my study. Please retum the completed survey in the envelope provided. I appreciate the time and effort that you contributed to the study. Again, your responses to the study will remain confidential. If you would like more information about the results of the study please include your name and address below.

113 APPENDIX E

REMINDER POSTCARD

114 Date

Last week a questionnaire seeking your knowledge and experience dealing with sexuality issues with clients was mailed to you. Your name was chosen randomly from a list of clinical AAMFT members.

If you have already completed and retumed the questionnaire to me, please accept my sincere gratitude. If not, please do so today. 1 am especially thankful for your participation because the results of this study will increase the understanding of how therapists address the sexuality needs of their clients.

If you did not receive a questiormaire, or if it was misplaced, please contact me and 1 will get another one in the mail to you today.

Kelli W. Hays, Ph. D. candidate Email: [email protected] Texas Tech University Phone: (817)657-4236 Lubbock, Texas 79409-1162

115 APPENDIX F

FOLLOW-UP LETTER AND REPLACEMENT QUESTIONNAIRE

116 Date

Name Address City, State Zip

About three weeks ago I sent a questionnaire to you that asked about your experience and training in addressing sexuality issues with clients. To the best of my knowledge, it has not yet been retumed.

The responses that I have received thus far represent a wide variety of both experience and training with sexuality issues. I am hopeful that the results are going to be helpful in advancing our field in this area.

I am writing again because of the importance that your questionnaire has for helping me obtain accurate results. It is only by hearing from everyone in the sample that I can be sure that the results are truly representative.

Please let me reassure of you of the protection of your confidentiality. A questionnaire identification number is printed on the back cover of the questionnaire so that 1 can check your name off of the mailing list when it is retumed. The list of names is then destroyed so that individual names cannot be connected to the results in any way. Protecting the confidentiality of your answers is very important to me, as well as the University.

I hope that you will take a few minutes to complete the questionnaire today, but if for any reason you prefer not to answer it, please let me know by leaving me a quick message via phone or email. Thank you in advance for your time and consideration in this matter.

Sincerely,

Kelli W. Hays, Ph.D. candidate Steven M. Harris, Ph.D., Advisor Texas Tech Univershy Human Development and Family Studies Lubbock, Texas 79409-1162 Texas Tech University Lubbock, Texas 79409-1162 Email: [email protected] Phone: (817)657-4236

117 APPENDIX G

OMITTED QUESTIONS THAT WERE IDENTIFIED

AS QUESTIONABLE BY THE

AUTHOR OF THE SKAT

118 1. Impotence is almost always a psychogenic disorder

2. Homosexuality comes from leaming and conditioning experiences.

3. The onset of secondary impotence preceded by a period of potency is often associated

with the influence of alcohol.

4. In some legal jurisdictions artificial insemination by a donor may make a woman

liable to suit for adultery.

5. The emotionally damaging consequences of a sexual offense against a child are more

often attributable to the attitudes of the adults who deal with the child than to the

experience itself.

6. Freshman medical students know more about sex than other college graduates.

119 APPENDIX H

ADDITIONAL OMITTED QUESTIONS THAT WERE

CONSIDERED IRRELEVANT OR OUTDATED

120 1. Sexual attitudes of children are molded by erotic literature.

2. In most instances, the biological sex will override the sex assigned by the child's

parents.

3. Habitual sexual promiscuity is the consequence of an above-average sex drive.

4. Age affects the sexual behavior of men more than it does women.'

5. More than a few people who are middle-aged or older practice masturbation.

6. Many women erroneously consider themselves to be frigid.

7. The two most widely used forms of contraception around the world are the condom

and withdrawal by the male (coitus intermptus).

8. Pomographic materials are responsible for much of today's aberrant sexual behavior.

9. LSD usually stimulates the sex drive.

10. Seven out often parents desire formal sex education in the schools.

11. For every female that masturbates four males do.

121